Orencia (abatacept) Document Number: MODA-0091

Transcription

1 Orencia (abatacept) Dcument Number: MODA-0091 Last Review Date: 09/19/2017 Date f Origin: 07/02/2010 Dates Reviewed: 07/2010, 09/2010, 12/2010, 02/15/11, 03/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/12, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 3/2014, 06/2014, 09/2014, 12/2014, 03/2015, 06/2015, 9/2015, 12/2015, 03/2016, 06/2016, 09/2016, 12/2016, 03/2017, 04/2017, 06/2017, 08/2017, 09/2017 I. Length f Authrizatin Cverage will be prvided fr 6 mnths and may be renewed. II. Dsing Limits A. Quantity Limit (max daily dse) [Pharmacy Benefit]: Orencia ClickJect 125 mg autinjectr: 4 syringes per 28 days Orencia 250 mg vials: Lading: 4 vials (1000 mg) at weeks 0, 2 & 4 Maintenance: 4 vials (1000 mg) per 28 days Orencia prefilled syringes (50 mg, 87.5 mg, r 125 mg): 4 syringes per 28 days B. Max Units (per dse and ver time) [Medical Benefit]: IV Frmulatin: Lading: 100 billable units at weeks 0, 2, & 4 Maintenance: 100 billable units per 4 weeks Subcutaneus frmulatin: III. 13 billable units (1 dse) every week Initial Apprval Criteria Site f care specialty infusin prgram requirements are met (refer t Mda Site f Care Plicy). Cverage is prvided in the fllwing cnditins: Patient is nt receiving cmbinatin therapy with TNF antagnists r ther bilgic respnse mdifier; AND Patient has been evaluated and screened fr the presence f latent TB infectin prir t initiating treatment; AND Patient has been evaluated and screened fr the presence f hepatitis B virus (HBV) prir t initiating treatment; AND Mda Health Plan, Inc. Medical Necessity Criteria Page 1/14

2 Patient des nt have an active infectin, including clinically imprtant lcalized infectins; AND Must nt be administered cncurrently with live vaccines; AND Rheumatid Arthritis (RA) Adult patient (18 years r lder); AND Dcumented mderate t severe active disease; AND Patient has had at least a 3 mnth trial and failure f previus therapy with ONE ral disease mdifying anti-rheumatic agent (DMARD) such as methtrexate, azathiprine, auranfin, hydrxychlrquine, penicillamine, sulfasalazine, r leflunmide; AND May be used as a single agent r in cmbinatin with ther DMARDS including methtrexate(mtx), unless cntraindicated Patient must try and have an inadequate respnse, cntraindicatin, r intlerance t at least a three (3) mnth trial f Enbrel AND Humira; OR Patient is cntinuing treatment Plyarticular Juvenile Idipathic Arthritis (pjia) Patient is age 2 r greater; AND Dcumented mderate t severe active plyarticular disease; AND Patient has had at least a 1 mnth trial and failure (unless cntraindicated r intlerant) f previus therapy with either ral nn-steridal anti-inflammatry drugs (NSAIDs) OR a systemic gluccrticid (prednisne, methylprednislne, etc.); AND May be used as single agent r in cmbinatin with methtrexate unless cntraindicated Patient must try and have an inadequate respnse, cntraindicatin, r intlerance t at least a three (3) mnth trial f Enbrel AND Humira; OR Patient is cntinuing treatment Psriatic Arthritis (PsA) Adult patient (18 years r lder); AND Dcumented mderate t severe active disease; AND Fr patients with predminantly axial disease OR active enthesitis and/r dactylitis, an adequate trial and failure f at least TWO (2) nn-steridal anti-inflammatry agents (NSAIDs), unless use is cntraindicated; OR Fr patients with peripheral arthritis, a trial and failure f at least a 3 mnth trial f ONE ral disease-mdifying anti-rheumatic agent (DMARD) such as methtrexate, azathiprine, sulfasalazine, r hydrxychlrquine Patient must try and have an inadequate respnse, cntraindicatin, r intlerance t at least a three (3) mnth trial f Enbrel AND Humira; OR Patient is cntinuing treatment FDA Apprved Indicatin(s) Mda Health Plan, Inc. Medical Necessity Criteria Page 2/14

3 IV. Renewal Criteria Cverage can be renewed based upn the fllwing criteria: Patient cntinues t meet criteria identified in sectin III; AND Disease respnse as indicated by imprvement in signs and symptms cmpared t baseline such as the number f tender and swllen jint cunts; AND Absence f unacceptable txicity frm the drug. Examples f unacceptable txicity include the fllwing: serius infectins, respiratry adverse events in thse with predispsing cnditins, etc.; AND Patient is receiving nging mnitring fr presence f TB r ther active infectins V. Dsage/Administratin Indicatin Rheumatid Arthritis and Psriatic Arthritis in adults Dse Intravenus Dsing Weight < 60kg: 500 mg at weeks 0, 2, & 4, then every 4 weeks thereafter Weight 60 t 100 kg: 750 mg at weeks 0, 2, & 4, then every 4 weeks thereafter Weight > 100 kg: 1,000 mg at weeks 0, 2, & 4, then every 4 weeks thereafter Subcutaneus Dsing (Orencia 125 mg Subcutaneus Injectin ONLY) Administer by subcutaneus injectin nce weekly May initiate with r withut an IV lading dse If initiated with an IV lading dse, a single weight-based infusin (see abve) shuld be fllwed by the first 125 mg subcutaneus injectin within a day Patients transitining frm ORENCIA intravenus therapy t subcutaneus administratin shuld administer the first subcutaneus dse instead f the next scheduled intravenus dse. Intravenus Dsing (patients aged 6 years r lder ONLY) Plyarticular Juvenile Idipathic Arthritis Weight < 75 kg: 10 mg/kg at weeks 0, 2, & 4, then every 4 weeks thereafter Weight 75 t 100 kg: 750 mg at weeks 0, 2, & 4, then every 4 weeks thereafter Weight > 100 kg: 1,000 mg at weeks 0, 2, & 4, then every 4 weeks thereafter Subcutaneus Dsing using prefilled syringes (patients aged 2 years r lder) Weight 10 t < 25 kg: 50 mg weekly Weight 25 t < 50 kg: 87.5 mg weekly Weight 50 kg: 125 mg weekly Mda Health Plan, Inc. Medical Necessity Criteria Page 3/14

4 VI. Billing Cde/Availability Infrmatin JCde: J0129 Injectin, Abatacept, 10 mg; 1 billable unit = 10mg (Cde may be used fr Medicare when drug administered under the direct supervisin f a physician, nt fr use when drug is self-administered) NDC: Orencia 250 mg 15 ml vial: xx Orencia ClickJect 125 mg/ml Autinjectr and prefilled syringe: xx Orencia prefilled syringe 50 mg/0.4 ml: xx Orencia prefilled syringe 87.5 mg/0.7 ml: xx VII. References 1. Orencia [package insert]. Princetn, NJ; Bristl-Myers Squibb; June Accessed August Singh JA, Saag KG, Bridges SL Jr, et al American Cllege f Rheumatlgy Guideline fr the Treatment f Rheumatid Arthritis. Arthritis Care Res (Hbken) Nv 6. di: /acr Natinal Institute fr Health and Clinical Excellence (NICE). Adalimumab, etanercept, infliximab, rituximab and abatacept fr the treatment f rheumatid arthritis after the failure f a TNF inhibitr. Lndn (UK): Natinal Institute fr Health and Clinical Excellence (NICE); 2010 Aug. 73 p. (Technlgy appraisal guidance; n. 195) 4. Beukelman T, Patkar NM, Saag KG, et al American Cllege f Rheumatlgy recmmendatins fr the treatment f juvenile idipathic arthritis: initiatin and safety mnitring f therapeutic agents fr the treatment f arthritis and systemic features. Arthritis Care Res (Hbken) Apr;63(4): Ringld S, Weiss PF, Beukelman T, et al update f the 2011 American Cllege f Rheumatlgy recmmendatins fr the treatment f juvenile idipathic arthritis: recmmendatins fr the medical therapy f children with systemic juvenile idipathic arthritis and tuberculsis screening amng children receiving bilgic medicatins. Arthritis Rheum Oct;65(10): DeWitt EM, Kimura Y, Beukelman T, et al. Cnsensus treatment plans fr new-nset systemic juvenile idipathic arthritis. Arthritis Care Res (Hbken) Jul;64(7): Gttlieb A, Krman NJ, Grdn KB, Feldman SR, Lebwhl M, K JY, Van Vrhees AS, Elmets CA, Lenardi CL, Beutner KR, Bhushan R, Menter A. Guidelines f care fr the management f psriasis and psriatic arthritis: Sectin 2. Psriatic arthritis: verview and guidelines f care fr treatment with an emphasis n the bilgics. J Am Acad Dermatl 2008 May;58(5): Gssec L, Smlen JS, Ramir S, et al. Eurpean League Against Rheumatism (EULAR) recmmendatins fr the management f psriatic arthritis with pharmaclgical therapies: 2015 update. Ann Rheum Dis Dec 7. pii: annrheumdis di: /annrheumdis Smlen JS, Landewe R, Bijilsma J, et al. EULAR recmmendatins fr the management f rheumatid arthritis with synthetic and bilgical disease-mdifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017; 76: Mda Health Plan, Inc. Medical Necessity Criteria Page 4/14

5 10. First Cast Service Optins, Inc. Lcal Cverage Determinatin (LCD): Abatacept (L33257). Centers fr Medicare & Medicaid Services, Inc. Updated n 07/01/2014 with effective date 10/01/2015. Accessed August Wiscnsin Physicians Service Insurance Crpratin. Lcal Cverage Determinatin (LCD): Drugs and Bilgics (Nn-chemtherapy) (L34741). Centers fr Medicare & Medicaid Services, Inc. Updated n 06/21/2017 with effective date 07/01/2017. Accessed August Appendix 1 Cvered Diagnsis Cdes ICD-10 L40.50 Arthrpathic psriasis, unspecified L40.51 Distal interphalangeal psriatic arthrpathy L40.52 Psriatic arthritis mutilans L40.53 Psriatic spndylitis L40.59 Other psriatic arthrpathy M05.10 Rheumatid lung disease with rheumatid arthritis f unspecified site M Rheumatid lung disease with rheumatid arthritis f right shulder M Rheumatid lung disease with rheumatid arthritis f left shulder M Rheumatid lung disease with rheumatid arthritis f unspecified shulder M Rheumatid lung disease with rheumatid arthritis f right elbw M Rheumatid lung disease with rheumatid arthritis f left elbw M Rheumatid lung disease with rheumatid arthritis f unspecified elbw M Rheumatid lung disease with rheumatid arthritis f right wrist M Rheumatid lung disease with rheumatid arthritis f left wrist M Rheumatid lung disease with rheumatid arthritis f unspecified wrist M Rheumatid lung disease with rheumatid arthritis f right hand M Rheumatid lung disease with rheumatid arthritis f left hand M Rheumatid lung disease with rheumatid arthritis f unspecified hand M Rheumatid lung disease with rheumatid arthritis f right hip M Rheumatid lung disease with rheumatid arthritis f left hip M Rheumatid lung disease with rheumatid arthritis f unspecified hip M Rheumatid lung disease with rheumatid arthritis f right knee M Rheumatid lung disease with rheumatid arthritis f left knee M Rheumatid lung disease with rheumatid arthritis f unspecified knee M Rheumatid lung disease with rheumatid arthritis f right ankle and ft M Rheumatid lung disease with rheumatid arthritis f left ankle and ft M Rheumatid lung disease with rheumatid arthritis f unspecified ankle and ft M05.19 Rheumatid lung disease with rheumatid arthritis f multiple sites M05.20 Rheumatid vasculitis with rheumatid arthritis f unspecified site M Rheumatid vasculitis with rheumatid arthritis f right shulder M Rheumatid vasculitis with rheumatid arthritis f left shulder M Rheumatid vasculitis with rheumatid arthritis f unspecified shulder M Rheumatid vasculitis with rheumatid arthritis f right elbw Mda Health Plan, Inc. Medical Necessity Criteria Page 5/14

6 M Rheumatid vasculitis with rheumatid arthritis f left elbw M Rheumatid vasculitis with rheumatid arthritis f unspecified elbw M Rheumatid vasculitis with rheumatid arthritis f right wrist M Rheumatid vasculitis with rheumatid arthritis f left wrist M Rheumatid vasculitis with rheumatid arthritis f unspecified wrist M Rheumatid vasculitis with rheumatid arthritis f right hand M Rheumatid vasculitis with rheumatid arthritis f left hand M Rheumatid vasculitis with rheumatid arthritis f unspecified hand M Rheumatid vasculitis with rheumatid arthritis f right hip M Rheumatid vasculitis with rheumatid arthritis f left hip M Rheumatid vasculitis with rheumatid arthritis f unspecified hip M Rheumatid vasculitis with rheumatid arthritis f right knee M Rheumatid vasculitis with rheumatid arthritis f left knee M Rheumatid vasculitis with rheumatid arthritis f unspecified knee M Rheumatid vasculitis with rheumatid arthritis f right ankle and ft M Rheumatid vasculitis with rheumatid arthritis f left ankle and ft M Rheumatid vasculitis with rheumatid arthritis f unspecified ankle and ft M05.29 Rheumatid vasculitis with rheumatid arthritis f multiple sites M05.30 Rheumatid heart disease with rheumatid arthritis f unspecified site M Rheumatid heart disease with rheumatid arthritis f right shulder M Rheumatid heart disease with rheumatid arthritis f left shulder M Rheumatid heart disease with rheumatid arthritis f unspecified shulder M Rheumatid heart disease with rheumatid arthritis f right elbw M Rheumatid heart disease with rheumatid arthritis f left elbw M Rheumatid heart disease with rheumatid arthritis f unspecified elbw M Rheumatid heart disease with rheumatid arthritis f right wrist M Rheumatid heart disease with rheumatid arthritis f left wrist M Rheumatid heart disease with rheumatid arthritis f unspecified wrist M Rheumatid heart disease with rheumatid arthritis f right hand M Rheumatid heart disease with rheumatid arthritis f left hand M Rheumatid heart disease with rheumatid arthritis f unspecified hand M Rheumatid heart disease with rheumatid arthritis f right hip M Rheumatid heart disease with rheumatid arthritis f left hip M Rheumatid heart disease with rheumatid arthritis f unspecified hip M Rheumatid heart disease with rheumatid arthritis f right knee M Rheumatid heart disease with rheumatid arthritis f left knee M Rheumatid heart disease with rheumatid arthritis f unspecified knee M Rheumatid heart disease with rheumatid arthritis f right ankle and ft M Rheumatid heart disease with rheumatid arthritis f left ankle and ft M Rheumatid heart disease with rheumatid arthritis f unspecified ankle and ft M05.39 Rheumatid heart disease with rheumatid arthritis f multiple sites Mda Health Plan, Inc. Medical Necessity Criteria Page 6/14

7 M05.40 Rheumatid mypathy with rheumatid arthritis f unspecified site M Rheumatid mypathy with rheumatid arthritis f right shulder M Rheumatid mypathy with rheumatid arthritis f left shulder M Rheumatid mypathy with rheumatid arthritis f unspecified shulder M Rheumatid mypathy with rheumatid arthritis f right elbw M Rheumatid mypathy with rheumatid arthritis f left elbw M Rheumatid mypathy with rheumatid arthritis f unspecified elbw M Rheumatid mypathy with rheumatid arthritis f right wrist M Rheumatid mypathy with rheumatid arthritis f left wrist M Rheumatid mypathy with rheumatid arthritis f unspecified wrist M Rheumatid mypathy with rheumatid arthritis f right hand M Rheumatid mypathy with rheumatid arthritis f left hand M Rheumatid mypathy with rheumatid arthritis f unspecified hand M Rheumatid mypathy with rheumatid arthritis f right hip M Rheumatid mypathy with rheumatid arthritis f left hip M Rheumatid mypathy with rheumatid arthritis f unspecified hip M Rheumatid mypathy with rheumatid arthritis f right knee M Rheumatid mypathy with rheumatid arthritis f left knee M Rheumatid mypathy with rheumatid arthritis f unspecified knee M Rheumatid mypathy with rheumatid arthritis f right ankle and ft M Rheumatid mypathy with rheumatid arthritis f left ankle and ft M Rheumatid mypathy with rheumatid arthritis f unspecified ankle and ft M05.49 Rheumatid mypathy with rheumatid arthritis f multiple sites M05.50 Rheumatid plyneurpathy with rheumatid arthritis f unspecified site M Rheumatid plyneurpathy with rheumatid arthritis f right shulder M Rheumatid plyneurpathy with rheumatid arthritis f left shulder M Rheumatid plyneurpathy with rheumatid arthritis f unspecified shulder M Rheumatid plyneurpathy with rheumatid arthritis f right elbw M Rheumatid plyneurpathy with rheumatid arthritis f left elbw M Rheumatid plyneurpathy with rheumatid arthritis f unspecified elbw M Rheumatid plyneurpathy with rheumatid arthritis f right wrist M Rheumatid plyneurpathy with rheumatid arthritis f left wrist M Rheumatid plyneurpathy with rheumatid arthritis f unspecified wrist M Rheumatid plyneurpathy with rheumatid arthritis f right hand M Rheumatid plyneurpathy with rheumatid arthritis f left hand M Rheumatid plyneurpathy with rheumatid arthritis f unspecified hand M Rheumatid plyneurpathy with rheumatid arthritis f right hip M Rheumatid plyneurpathy with rheumatid arthritis f left hip M Rheumatid plyneurpathy with rheumatid arthritis f unspecified hip M Rheumatid plyneurpathy with rheumatid arthritis f right knee M Rheumatid plyneurpathy with rheumatid arthritis f left knee Mda Health Plan, Inc. Medical Necessity Criteria Page 7/14

8 M Rheumatid plyneurpathy with rheumatid arthritis f unspecified knee M Rheumatid plyneurpathy with rheumatid arthritis f right ankle and ft M Rheumatid plyneurpathy with rheumatid arthritis f left ankle and ft M Rheumatid plyneurpathy with rheumatid arthritis f unspecified ankle and ft M05.59 Rheumatid plyneurpathy with rheumatid arthritis f multiple sites M05.60 Rheumatid arthritis f unspecified site with f ther rgans and systems M Rheumatid arthritis f right shulder with f ther rgans and systems M Rheumatid arthritis f left shulder with f ther rgans and systems M Rheumatid arthritis f unspecified shulder with f ther rgans and systems M Rheumatid arthritis f right elbw with f ther rgans and systems M Rheumatid arthritis f left elbw with f ther rgans and systems M Rheumatid arthritis f unspecified elbw with f ther rgans and systems M Rheumatid arthritis f right wrist with f ther rgans and systems M Rheumatid arthritis f left wrist with f ther rgans and systems M Rheumatid arthritis f unspecified wrist with f ther rgans and systems M Rheumatid arthritis f right hand with f ther rgans and systems M Rheumatid arthritis f left hand with f ther rgans and systems M Rheumatid arthritis f unspecified hand with f ther rgans and systems M Rheumatid arthritis f right hip with f ther rgans and systems M Rheumatid arthritis f left hip with f ther rgans and systems M Rheumatid arthritis f unspecified hip with f ther rgans and systems M Rheumatid arthritis f right knee with f ther rgans and systems M Rheumatid arthritis f left knee with f ther rgans and systems M Rheumatid arthritis f unspecified knee with f ther rgans and systems M Rheumatid arthritis f right ankle and ft with f ther rgans and systems M Rheumatid arthritis f left ankle and ft with f ther rgans and systems M Rheumatid arthritis f unspecified ankle and ft with f ther rgans and systems M05.69 Rheumatid arthritis f multiple sites with f ther rgans and systems M05.70 Rheumatid arthritis with rheumatid factr f unspecified site withut rgan r systems M Rheumatid arthritis with rheumatid factr f right shulder withut rgan r systems M Rheumatid arthritis with rheumatid factr f left shulder withut rgan r systems M Rheumatid arthritis with rheumatid factr f unspecified shulder withut rgan r systems M Rheumatid arthritis with rheumatid factr f right elbw withut rgan r systems M Rheumatid arthritis with rheumatid factr f left elbw withut rgan r systems M Rheumatid arthritis with rheumatid factr f unspecified elbw withut rgan r systems M Rheumatid arthritis with rheumatid factr f right wrist withut rgan r systems M Rheumatid arthritis with rheumatid factr f left wrist withut rgan r systems M Rheumatid arthritis with rheumatid factr f unspecified wrist withut rgan r systems Mda Health Plan, Inc. Medical Necessity Criteria Page 8/14

9 M Rheumatid arthritis with rheumatid factr f right hand withut rgan r systems M Rheumatid arthritis with rheumatid factr f left hand withut rgan r systems M Rheumatid arthritis with rheumatid factr f unspecified hand withut rgan r systems M Rheumatid arthritis with rheumatid factr f right hip withut rgan r systems M Rheumatid arthritis with rheumatid factr f left hip withut rgan r systems M Rheumatid arthritis with rheumatid factr f unspecified hip withut rgan r systems M Rheumatid arthritis with rheumatid factr f right knee withut rgan r systems M Rheumatid arthritis with rheumatid factr f left knee withut rgan r systems M Rheumatid arthritis with rheumatid factr f unspecified knee withut rgan r systems M Rheumatid arthritis with rheumatid factr f right ankle and ft withut rgan r systems M Rheumatid arthritis with rheumatid factr f left ankle and ft withut rgan r systems M Rheumatid arthritis with rheumatid factr f unspecified ankle and ft withut rgan r systems M05.79 Rheumatid arthritis with rheumatid factr f multiple sites withut rgan r systems M05.80 Other rheumatid arthritis with rheumatid factr f unspecified site M Other rheumatid arthritis with rheumatid factr f right shulder M Other rheumatid arthritis with rheumatid factr f left shulder M Other rheumatid arthritis with rheumatid factr f unspecified shulder M Other rheumatid arthritis with rheumatid factr f right elbw M Other rheumatid arthritis with rheumatid factr f left elbw M Other rheumatid arthritis with rheumatid factr f unspecified elbw M Other rheumatid arthritis with rheumatid factr f right wrist M Other rheumatid arthritis with rheumatid factr f left wrist M Other rheumatid arthritis with rheumatid factr f unspecified wrist M Other rheumatid arthritis with rheumatid factr f right hand M Other rheumatid arthritis with rheumatid factr f left hand M Other rheumatid arthritis with rheumatid factr f unspecified hand M Other rheumatid arthritis with rheumatid factr f right hip M Other rheumatid arthritis with rheumatid factr f left hip M Other rheumatid arthritis with rheumatid factr f unspecified hip M Other rheumatid arthritis with rheumatid factr f right knee M Other rheumatid arthritis with rheumatid factr f left knee M Other rheumatid arthritis with rheumatid factr f unspecified knee M Other rheumatid arthritis with rheumatid factr f right ankle and ft M Other rheumatid arthritis with rheumatid factr f left ankle and ft M Other rheumatid arthritis with rheumatid factr f unspecified ankle and ft M05.89 Other rheumatid arthritis with rheumatid factr f multiple sites Mda Health Plan, Inc. Medical Necessity Criteria Page 9/14

10 M05.9 Rheumatid arthritis with rheumatid factr, unspecified M06.00 Rheumatid arthritis withut rheumatid factr, unspecified site M Rheumatid arthritis withut rheumatid factr, right shulder M Rheumatid arthritis withut rheumatid factr, left shulder M Rheumatid arthritis withut rheumatid factr, unspecified shulder M Rheumatid arthritis withut rheumatid factr, right elbw M Rheumatid arthritis withut rheumatid factr, left elbw M Rheumatid arthritis withut rheumatid factr, unspecified elbw M Rheumatid arthritis withut rheumatid factr, right wrist M Rheumatid arthritis withut rheumatid factr, left wrist M Rheumatid arthritis withut rheumatid factr, unspecified wrist M Rheumatid arthritis withut rheumatid factr, right hand M Rheumatid arthritis withut rheumatid factr, left hand M Rheumatid arthritis withut rheumatid factr, unspecified hand M Rheumatid arthritis withut rheumatid factr, right hip M Rheumatid arthritis withut rheumatid factr, left hip M Rheumatid arthritis withut rheumatid factr, unspecified hip M Rheumatid arthritis withut rheumatid factr, right knee M Rheumatid arthritis withut rheumatid factr, left knee M Rheumatid arthritis withut rheumatid factr, unspecified knee M Rheumatid arthritis withut rheumatid factr, right ankle and ft M Rheumatid arthritis withut rheumatid factr, left ankle and ft M Rheumatid arthritis withut rheumatid factr, unspecified ankle and ft M06.08 Rheumatid arthritis withut rheumatid factr, vertebrae M06.09 Rheumatid arthritis withut rheumatid factr, multiple sites M06.80 Other specified rheumatid arthritis, unspecified site M Other specified rheumatid arthritis, right shulder M Other specified rheumatid arthritis, left shulder M Other specified rheumatid arthritis, unspecified shulder M Other specified rheumatid arthritis, right elbw M Other specified rheumatid arthritis, left elbw M Other specified rheumatid arthritis, unspecified elbw M Other specified rheumatid arthritis, right wrist M Other specified rheumatid arthritis, left wrist M Other specified rheumatid arthritis, unspecified wrist M Other specified rheumatid arthritis, right hand M Other specified rheumatid arthritis, left hand M Other specified rheumatid arthritis, unspecified hand M Other specified rheumatid arthritis, right hip M Other specified rheumatid arthritis, left hip M Other specified rheumatid arthritis, unspecified hip Mda Health Plan, Inc. Medical Necessity Criteria Page 10/14

11 M Other specified rheumatid arthritis, right knee M Other specified rheumatid arthritis, left knee M Other specified rheumatid arthritis, unspecified knee M Other specified rheumatid arthritis, right ankle and ft M Other specified rheumatid arthritis, left ankle and ft M Other specified rheumatid arthritis, unspecified ankle and ft M06.88 Other specified rheumatid arthritis, vertebrae M06.89 Other specified rheumatid arthritis, multiple sites M06.9 Rheumatid arthritis, unspecified M08.00 Unspecified juvenile rheumatid arthritis f unspecified site M Unspecified juvenile rheumatid arthritis, right shulder M Unspecified juvenile rheumatid arthritis, left shulder M Unspecified juvenile rheumatid arthritis, unspecified shulder M Unspecified juvenile rheumatid arthritis, right elbw M Unspecified juvenile rheumatid arthritis, left elbw M Unspecified juvenile rheumatid arthritis, unspecified elbw M Unspecified juvenile rheumatid arthritis, right wrist M Unspecified juvenile rheumatid arthritis, left wrist M Unspecified juvenile rheumatid arthritis, unspecified wrist M Unspecified juvenile rheumatid arthritis, right hand M Unspecified juvenile rheumatid arthritis, left hand M Unspecified juvenile rheumatid arthritis, unspecified hand M Unspecified juvenile rheumatid arthritis, right hip M Unspecified juvenile rheumatid arthritis, left hip M Unspecified juvenile rheumatid arthritis, unspecified hip M Unspecified juvenile rheumatid arthritis, right knee M Unspecified juvenile rheumatid arthritis, left knee M Unspecified juvenile rheumatid arthritis, unspecified knee M Unspecified juvenile rheumatid arthritis, right ankle and ft M Unspecified juvenile rheumatid arthritis, left ankle and ft M Unspecified juvenile rheumatid arthritis, unspecified ankle and ft M08.08 Unspecified juvenile rheumatid arthritis, vertebrae M08.09 Unspecified juvenile rheumatid arthritis, multiple sites M08.20 Juvenile rheumatid arthritis with systemic nset, unspecified site M Juvenile rheumatid arthritis with systemic nset, right shulder M Juvenile rheumatid arthritis with systemic nset, left shulder M Juvenile rheumatid arthritis with systemic nset, unspecified shulder M Juvenile rheumatid arthritis with systemic nset, right elbw M Juvenile rheumatid arthritis with systemic nset, left elbw M Juvenile rheumatid arthritis with systemic nset, unspecified elbw M Juvenile rheumatid arthritis with systemic nset, right wrist Mda Health Plan, Inc. Medical Necessity Criteria Page 11/14

12 M Juvenile rheumatid arthritis with systemic nset, left wrist M Juvenile rheumatid arthritis with systemic nset, unspecified wrist M Juvenile rheumatid arthritis with systemic nset, right hand M Juvenile rheumatid arthritis with systemic nset, left hand M Juvenile rheumatid arthritis with systemic nset, unspecified hand M Juvenile rheumatid arthritis with systemic nset, right hip M Juvenile rheumatid arthritis with systemic nset, left hip M Juvenile rheumatid arthritis with systemic nset, unspecified hip M Juvenile rheumatid arthritis with systemic nset, right knee M Juvenile rheumatid arthritis with systemic nset, left knee M Juvenile rheumatid arthritis with systemic nset, unspecified knee M Juvenile rheumatid arthritis with systemic nset, right ankle and ft M Juvenile rheumatid arthritis with systemic nset, left ankle and ft M Juvenile rheumatid arthritis with systemic nset, unspecified ankle and ft M08.28 Juvenile rheumatid arthritis with systemic nset, vertebrae M08.29 Juvenile rheumatid arthritis with systemic nset, multiple sites M08.3 Juvenile rheumatid plyarthritis (sernegative) M08.3 Juvenile rheumatid plyarthritis (sernegative) M08.40 Pauciarticular juvenile rheumatid arthritis, unspecified site M08.40 Pauciarticular juvenile rheumatid arthritis, unspecified site M Pauciarticular juvenile rheumatid arthritis, right shulder M Pauciarticular juvenile rheumatid arthritis, left shulder M Pauciarticular juvenile rheumatid arthritis, unspecified shulder M Pauciarticular juvenile rheumatid arthritis, right elbw M Pauciarticular juvenile rheumatid arthritis, left elbw M Pauciarticular juvenile rheumatid arthritis, unspecified elbw M Pauciarticular juvenile rheumatid arthritis, right wrist M Pauciarticular juvenile rheumatid arthritis, left wrist M Pauciarticular juvenile rheumatid arthritis, unspecified wrist M Pauciarticular juvenile rheumatid arthritis, right hand M Pauciarticular juvenile rheumatid arthritis, left hand M Pauciarticular juvenile rheumatid arthritis, unspecified hand M Pauciarticular juvenile rheumatid arthritis, right hip M Pauciarticular juvenile rheumatid arthritis, left hip M Pauciarticular juvenile rheumatid arthritis, unspecified hip M Pauciarticular juvenile rheumatid arthritis, right knee M Pauciarticular juvenile rheumatid arthritis, left knee M Pauciarticular juvenile rheumatid arthritis, unspecified knee M Pauciarticular juvenile rheumatid arthritis, right ankle and ft M Pauciarticular juvenile rheumatid arthritis, left ankle and ft M Pauciarticular juvenile rheumatid arthritis, unspecified ankle and ft Mda Health Plan, Inc. Medical Necessity Criteria Page 12/14

13 M08.48 Pauciarticular juvenile rheumatid arthritis, vertebrae M08.80 Other juvenile arthritis, unspecified site M Other juvenile arthritis, right shulder M Other juvenile arthritis, left shulder M Other juvenile arthritis, unspecified shulder M Other juvenile arthritis, right elbw M Other juvenile arthritis, left elbw M Other juvenile arthritis, unspecified elbw M Other juvenile arthritis, right wrist M Other juvenile arthritis, left wrist M Other juvenile arthritis, unspecified wrist M Other juvenile arthritis, right hand M Other juvenile arthritis, left hand M Other juvenile arthritis, unspecified hand M Other juvenile arthritis, right hip M Other juvenile arthritis, left hip M Other juvenile arthritis, unspecified hip M Other juvenile arthritis, right knee M Other juvenile arthritis, left knee M Other juvenile arthritis, unspecified knee M Other juvenile arthritis, right ankle and ft M Other juvenile arthritis, left ankle and ft M Other juvenile arthritis, unspecified ankle and ft M08.88 Other juvenile arthritis, ther specified site M08.89 Other juvenile arthritis, multiple sites M08.90 Juvenile arthritis, unspecified, unspecified site M Juvenile arthritis, unspecified, right shulder M Juvenile arthritis, unspecified, left shulder M Juvenile arthritis, unspecified, unspecified shulder M Juvenile arthritis, unspecified, right elbw M Juvenile arthritis, unspecified, left elbw M Juvenile arthritis, unspecified, unspecified elbw M Juvenile arthritis, unspecified, right wrist M Juvenile arthritis, unspecified, left wrist M Juvenile arthritis, unspecified, unspecified wrist M Juvenile arthritis, unspecified, right hand M Juvenile arthritis, unspecified, left hand M Juvenile arthritis, unspecified, unspecified hand M Juvenile arthritis, unspecified, right hip M Juvenile arthritis, unspecified, left hip M Juvenile arthritis, unspecified, unspecified hip Mda Health Plan, Inc. Medical Necessity Criteria Page 13/14

14 M Juvenile arthritis, unspecified, right knee M Juvenile arthritis, unspecified, left knee M Juvenile arthritis, unspecified, unspecified knee M Juvenile arthritis, unspecified, right ankle and ft M Juvenile arthritis, unspecified, left ankle and ft M Juvenile arthritis, unspecified, unspecified ankle and ft M08.98 Juvenile arthritis, unspecified, vertebrae M08.99 Juvenile arthritis, unspecified, multiple sites Appendix 2 Centers fr Medicare and Medicaid Services (CMS) Medicare cverage fr utpatient (Part B) drugs is utlined in the Medicare Benefit Plicy Manual (Pub ), Chapter 15, 50 Drugs and Bilgicals. In additin, Natinal Cverage Determinatin (NCD) and Lcal Cverage Determinatins (LCDs) may exist and cmpliance with these plicies is required where applicable. They can be fund at: Additinal indicatins may be cvered at the discretin f the health plan. Medicare Part B Cvered Diagnsis Cdes (applicable t existing NCD/LCD): Jurisdictin(s): N NCD/LCD Dcument (s): L33257 Jurisdictin(s): 5, 8 NCD/LCD Dcument (s): L Medicare Part B Administrative Cntractr (MAC) Jurisdictins Jurisdictin Applicable State/US Territry Cntractr E (1) CA, HI, NV, AS, GU, CNMI Nridian Healthcare Slutins, LLC F (2 & 3) AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ Nridian Healthcare Slutins, LLC 5 KS, NE, IA, MO Wiscnsin Physicians Service Insurance Crp (WPS) 6 MN, WI, IL Natinal Gvernment Services, Inc. (NGS) H (4 & 7) LA, AR, MS, TX, OK, CO, NM Nvitas Slutins, Inc. 8 MI, IN Wiscnsin Physicians Service Insurance Crp (WPS) N (9) FL, PR, VI First Cast Service Optins, Inc. J (10) TN, GA, AL Cahaba Gvernment Benefit Administratrs, LLC M (11) NC, SC, WV, VA (excluding belw) Palmett GBA, LLC L (12) DE, MD, PA, NJ, DC (includes Arlingtn & Fairfax cunties and the city f Alexandria in VA) K (13 & 14) NY, CT, MA, RI, VT, ME, NH Nvitas Slutins, Inc. Natinal Gvernment Services, Inc. (NGS) 15 KY, OH CGS Administratrs, LLC Mda Health Plan, Inc. Medical Necessity Criteria Page 14/14