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2 Page 1 of 23 d Rituximab (Rituxan ) Palmetto GBA Jump to Section... Please note: This is a Future LCD. Please note: This is a Draft policy. Proposed/Draft LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed/Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor. Contractor Name Contract Number Contract Type Palmetto GBA MAC - Part A Associated Contract Numbers (MAC - Part A ) Palmetto GBA, (MAC - Part A ) Palmetto GBA, (MAC - Part A ) Palmetto GBA Proposed/Draft LCD Information

3 Page 2 of 23 Source LCD ID N/A Proposed LCD ID Original ICD-9 LCD ID Proposed LCD Version Number Proposed LCD Title AMA CPT / ADA CDT Copyright Statement CMS National Coverage Policy DL35185 Not applicable 2 Rituximab (Rituxan ) CPT only copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright (c) American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Title XVIII of the Social Security Act(SSA) 1862(a)(1)(A), Allows coverage and payment for only those services that are considered to be medically reasonable and necessary. Title XVIII of the Social Security Act (SSA) 1861(t)(2)(B), Drugs and Biologicals Title XVIII of the Social Security Act (SSA) 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim. Title XVIII of the Social Security Act (SSA) 1862(a)(1)(D), Investigational or Experimental. CMS Internet-Only Manual, Pub , Medicare Benefit Policy Manual, Chapter 15, Section 50; , , , ; Drugs and Biologicals. CMS Internet-Only Manual, Pub , Medicare Claims Processing Manual, Chapter 17, Section 40; Discarded Drugs and Biologicals Jurisdiction SC Coverage Guidance Coverage Indications, Limitations and/or Medical Necessity Rituxan(rituximab) is a genetically engineered chimeric murine/human monoclonal IgG1 kappa antibody directed against the CD20 antigen. Rituximab binds specifically to the antigen CD20 (human B-lymphocyte-restricted differentiation antigen, Bp35), a hydrophobic transmembrane protein with a molecular weight of approximately 35 kd located on pre-b and mature B lymphocytes. The antigen is expressed on > 90% of B-cell Non-Hodgkin s Lymphomas (NHL), but the antigen is not found on hematopoietic stem cells, pro-b-cells, normal plasma cells or other

4 Page 3 of 23 normal tissues. B cells are believed to play a role in the pathogenesis of rheumatoid arthritis (RA) and associated chronic synovitis. In Non-Hodgkin s Lymphoma (NHL) patients, administration of Rituxan resulted in depletion of circulating and tissue-based B cells. In Wegeners Granulomatosis with Polyangiitis and Microscopic Polyangiitis patients, peripheral blood CD19 B-cells depleted to less than 10 cells/μl following the first two infusions of Rituxan, and remained at that level in most (84%) patients through Month 6. By Month 12, the majority of patients (81%) showed signs of B-cell return with counts >10 cells/μl Rituximab is indicated for the following FDA approved uses: 1. Non Hodgkin s Lymphoma (NHL Rituxan(rituximab)is indicated for the treatment of patients with: Relapsed or refractory, low-grade or follicular, CD20-positive, B-cell NHL as a single agent. Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in patients achieving a complete or partial response to Rituxan in combination with chemotherapy, as single-agent maintenance therapy. Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after first-line CVP chemotherapy. Previously untreated diffuse large B-cell, CD20-positive NHL in combination with CHOP (Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone)or other anthracycline-based chemotherapy regimens. 2.Chronic Lymphocytic Leukemia (CLL) Rituxan (rituximab) is indicated, in combination with fludarabine and cyclophosphamide (FC), for the treatment of patients with previously untreated and previously treated CD20-positive CLL. 3. Rheumatoid Arthritis (RA) Rituxan (rituximab) in combination with methotrexate is indicated for the treatment of adult patients with moderately- to severely- active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies. 4. Granulomatosis with Polyangiitis (GPA) (Wegener s Granulomatosis) and Microscopic Polyangiitis(MPA) Rituxan(rituximab), in combination with glucocorticoids, is indicated for the treatment of adult patients with Granulomatosis with Polyangiitis (GPA) (Wegener s Granulomatosis) and Microscopic Polyangiitis (MPA). 5. Accepted Off-label Uses Approved by Palmetto GBA Second-line or salvage therapy with or without radiation therapy (RT) prior to autologous stem cell rescue for progressive disease or for relapsed disease in patients initially treated with chemotherapy with or without RT in combination with bendamustine. Low grade or follicular CD20-positive, B-cell non-hodgkin s lymphomas (re-induction treatment appropriate for responders and patients with stable disease). Intermediate and high grade NHL when used as a single agent, in combination with a CHOP (Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone) chemotherapy regimen, or in combination with other agents active in the disease. Immune or idiopathic thrombocytopenia purpura Evans syndrome Waldenstrom s Macroglobulinemia

5 Page 4 of 23 For the treatment of refractory thrombotic thrombocytopenic purpura (TTP) for patients who do not respond to plasmapheresis. Autoimmune hemolytic anemia - Rituximab is covered for those patients with autoimmune hemolytic anemia condition that is refractory to conventional treatment (e.g., corticosteroid treatment and splenectomy). Multifocal Motor Neuropathy (NMN) second line (as a second line therapy) Multiple Sclerosis, relapsing, remitting (RRMS) (as a third line therapy) Neuromyelitis Optica Polymyositis (as a second or third line therapy) Myasthenia Gravis Anti-MAG Polyneuropathy Other off label uses will not be covered at this time. Proposed/Draft Process Information Associated Information Documentation Requirements Medical records must substantiate the medical need for the use of these chemotherapy drugs by clearly indicating the diagnoses for which these drugs are being used. We would expect the disease, the type of malignancy if cancer is the diagnosis; the staging, if applicable; all prior therapy and the patient s response to that therapy. For lymphoma patients receiving Rituximab, an explanation of lymphoma type and previous treatment(s) should be maintained in the medical record. All the documentation suggested here is usually found in the history and physical or the office/progress notes and must be available to Palmetto GBA on request. If the provider is other than the ordering/referring physician, that provider must maintain copies of the ordering/referring physician s order for the chemotherapy drug. The ordering/referring physician must state the clinical indication/medical need for using the chemotherapy drug in the order. For the off-label indication of autoimmune hemolytic anemia, in addition to the diagnosis and prior therapy requirements, other documentation required in the medical record: hemoglobin and hematocrit, reticulocyte count, bilirubin, liver function tests, and patient's subjective complaints. Sources of Information and Basis for Decision 1.Rituxan(rituximab) [package insert] Genentech, Inc. 1 DNA Way, South San Francisco, CA 2.Colombat P, Salles G, Brousse N, et al. Rituximab (anti-cd20 monoclonal antibody) as a single first-line therapy for patients with follicular lymphoma with a low tumor burden: clinical and molecular evaluation. Journal American Society of Hematology. 2001;97(1): This article supports off-labeled indications (1st line therapy) for this drug. 3.Edwards JC, Szczepanski L, Szechinski J, et al. Efficacy of B-Cell Targeted Therapy with Rituximab in Patients with Rheumatoid Arthritis. N Engl J Med. Jun 2004;350(25): Heidel, F., Lipka, D., et al. Addition of Rituximab to standard therapy improves response rate and progression-free survival in relapsed or refractory thrombotic thrombocytopenia purpura and autoimmune hemolytic anemia. Thrombosis and Hemostasis. 2007;97(2) National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium (2012).

6 Page 5 of 23 Rituximab. 6.National Comprehensive Cancer Network. Hodgkin Lymphoma: Principles of systemic therapy. Clinical Practice Guidelines in Oncology. 2012;1. HODG-B, 2. 7.Pamuk G, Turgut B, et al. The successful treatment of refractory autoimmune hemolytic anemia with rituximab in a patient with chronic lymphocytic leukemia.american Journal of Hematology. 2006;81: Vose, J, Link, B, Grossbard M, Czuczman M, Grillo-Lopez A, Gilman P, et al. Phase II study of Rituximab in combination with CHOP chemotherapy in patients with previously untreated, aggressive non-hodgkin s lymphoma. Journal of Clinical Oncology. 2001;19(2): LCD L29271, Rituxan, First Coast Service Options, Inc. 6/08/12 Open Meetings Meeting Date Meeting Information State 04/28/2014 via telephone conference North Carolina, South Carolina, Virginia, West Virginia Comment Period Start Date Comment Period End Date Released to Final LCD Date Reason for Proposed LCD Proposed LCD Contact 04/28/ /12/2014 Not yet released. Provider Education/Guidance Margaret Cox Palmetto GBA PO Box Columbia, SC Margaret.Anne.Cox@Palmettogba.com Coding Information Bill Type Codes 011x Hospital Inpatient (Including Medicare Part A) 012x 013x 018x Hospital Inpatient (Medicare Part B only) Hospital Outpatient Hospital - Swing Beds

7 Page 6 of x Skilled Nursing - Inpatient (Including Medicare Part A) 022x 085x Skilled Nursing - Inpatient (Medicare Part B only) Critical Access Hospital Revenue Codes 0250 Pharmacy - General Classification 0636 Pharmacy - Drugs Requiring Detailed Coding CPT/HCPCS Codes Group 1: Paragraph Group 1: Codes J9310 INJECTION, RITUXIMAB, 100 MG Does the CPT 30% Coding Rule Apply? ICD-10 Codes that Support Medical Necessity Note: Performance is optimized by using code ranges. No Group 1: Paragraph Group 1: Codes C81.00 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site C81.01 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck C81.02 Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes C81.03 Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes C81.04 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of axilla and upper limb C81.05 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of inguinal region and lower limb C81.06 Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes C81.07 Nodular lymphocyte predominant Hodgkin lymphoma, spleen C81.08 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of multiple sites C81.09 Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites C81.10 Nodular sclerosis classical Hodgkin lymphoma, unspecified site C81.11 Nodular sclerosis classical Hodgkin lymphoma, lymph nodes of head, face, and neck C81.12 Nodular sclerosis classical Hodgkin lymphoma, intrathoracic lymph nodes C81.13 Nodular sclerosis classical Hodgkin lymphoma, intra-abdominal lymph nodes C81.14 Nodular sclerosis classical Hodgkin lymphoma, lymph nodes of axilla and upper limb C81.15 Nodular sclerosis classical Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

8 Page 7 of 23 C81.16 Nodular sclerosis classical Hodgkin lymphoma, intrapelvic lymph nodes C81.17 Nodular sclerosis classical Hodgkin lymphoma, spleen C81.18 Nodular sclerosis classical Hodgkin lymphoma, lymph nodes of multiple sites C81.19 Nodular sclerosis classical Hodgkin lymphoma, extranodal and solid organ sites C81.20 Mixed cellularity classical Hodgkin lymphoma, unspecified site C81.21 Mixed cellularity classical Hodgkin lymphoma, lymph nodes of head, face, and neck C81.22 Mixed cellularity classical Hodgkin lymphoma, intrathoracic lymph nodes C81.23 Mixed cellularity classical Hodgkin lymphoma, intra-abdominal lymph nodes C81.24 Mixed cellularity classical Hodgkin lymphoma, lymph nodes of axilla and upper limb C81.25 Mixed cellularity classical Hodgkin lymphoma, lymph nodes of inguinal region and lower limb C81.26 Mixed cellularity classical Hodgkin lymphoma, intrapelvic lymph nodes C81.27 Mixed cellularity classical Hodgkin lymphoma, spleen C81.28 Mixed cellularity classical Hodgkin lymphoma, lymph nodes of multiple sites C81.29 Mixed cellularity classical Hodgkin lymphoma, extranodal and solid organ sites C81.30 Lymphocyte depleted classical Hodgkin lymphoma, unspecified site C81.31 Lymphocyte depleted classical Hodgkin lymphoma, lymph nodes of head, face, and neck C81.32 Lymphocyte depleted classical Hodgkin lymphoma, intrathoracic lymph nodes C81.33 Lymphocyte depleted classical Hodgkin lymphoma, intra-abdominal lymph nodes C81.34 Lymphocyte depleted classical Hodgkin lymphoma, lymph nodes of axilla and upper limb C81.35 Lymphocyte depleted classical Hodgkin lymphoma, lymph nodes of inguinal region and lower limb C81.36 Lymphocyte depleted classical Hodgkin lymphoma, intrapelvic lymph nodes C81.37 Lymphocyte depleted classical Hodgkin lymphoma, spleen C81.38 Lymphocyte depleted classical Hodgkin lymphoma, lymph nodes of multiple sites C81.39 Lymphocyte depleted classical Hodgkin lymphoma, extranodal and solid organ sites C81.40 Lymphocyte-rich classical Hodgkin lymphoma, unspecified site C81.41 Lymphocyte-rich classical Hodgkin lymphoma, lymph nodes of head, face, and neck C81.42 Lymphocyte-rich classical Hodgkin lymphoma, intrathoracic lymph nodes C81.43 Lymphocyte-rich classical Hodgkin lymphoma, intra-abdominal lymph nodes C81.44 Lymphocyte-rich classical Hodgkin lymphoma, lymph nodes of axilla and upper limb C81.45 Lymphocyte-rich classical Hodgkin lymphoma, lymph nodes of inguinal region and lower limb C81.46 Lymphocyte-rich classical Hodgkin lymphoma, intrapelvic lymph nodes

9 Page 8 of 23 C81.47 Lymphocyte-rich classical Hodgkin lymphoma, spleen C81.48 Lymphocyte-rich classical Hodgkin lymphoma, lymph nodes of multiple sites C81.49 Lymphocyte-rich classical Hodgkin lymphoma, extranodal and solid organ sites C81.70 Other classical Hodgkin lymphoma, unspecified site C81.71 Other classical Hodgkin lymphoma, lymph nodes of head, face, and neck C81.72 Other classical Hodgkin lymphoma, intrathoracic lymph nodes C81.73 Other classical Hodgkin lymphoma, intra-abdominal lymph nodes C81.74 Other classical Hodgkin lymphoma, lymph nodes of axilla and upper limb C81.75 Other classical Hodgkin lymphoma, lymph nodes of inguinal region and lower limb C81.76 Other classical Hodgkin lymphoma, intrapelvic lymph nodes C81.77 Other classical Hodgkin lymphoma, spleen C81.78 Other classical Hodgkin lymphoma, lymph nodes of multiple sites C81.79 Other classical Hodgkin lymphoma, extranodal and solid organ sites C81.90 Hodgkin lymphoma, unspecified, unspecified site C81.91 Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck C81.92 Hodgkin lymphoma, unspecified, intrathoracic lymph nodes C81.93 Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes C81.94 Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb C81.95 Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb C81.96 Hodgkin lymphoma, unspecified, intrapelvic lymph nodes C81.97 Hodgkin lymphoma, unspecified, spleen C81.98 Hodgkin lymphoma, unspecified, lymph nodes of multiple sites C81.99 Hodgkin lymphoma, unspecified, extranodal and solid organ sites C82.00 Follicular lymphoma grade I, unspecified site C82.01 Follicular lymphoma grade I, lymph nodes of head, face, and neck C82.02 Follicular lymphoma grade I, intrathoracic lymph nodes C82.03 Follicular lymphoma grade I, intra-abdominal lymph nodes C82.04 Follicular lymphoma grade I, lymph nodes of axilla and upper limb C82.05 Follicular lymphoma grade I, lymph nodes of inguinal region and lower limb C82.06 Follicular lymphoma grade I, intrapelvic lymph nodes C82.07 Follicular lymphoma grade I, spleen C82.08 Follicular lymphoma grade I, lymph nodes of multiple sites C82.09 Follicular lymphoma grade I, extranodal and solid organ sites C82.10 Follicular lymphoma grade II, unspecified site C82.11 Follicular lymphoma grade II, lymph nodes of head, face, and neck C82.12 Follicular lymphoma grade II, intrathoracic lymph nodes C82.13 Follicular lymphoma grade II, intra-abdominal lymph nodes C82.14 Follicular lymphoma grade II, lymph nodes of axilla and upper limb

10 Page 9 of 23 C82.15 Follicular lymphoma grade II, lymph nodes of inguinal region and lower limb C82.16 Follicular lymphoma grade II, intrapelvic lymph nodes C82.17 Follicular lymphoma grade II, spleen C82.18 Follicular lymphoma grade II, lymph nodes of multiple sites C82.19 Follicular lymphoma grade II, extranodal and solid organ sites C82.20 Follicular lymphoma grade III, unspecified, unspecified site C82.21 Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck C82.22 Follicular lymphoma grade III, unspecified, intrathoracic lymph nodes C82.23 Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes C82.24 Follicular lymphoma grade III, unspecified, lymph nodes of axilla and upper limb C82.25 Follicular lymphoma grade III, unspecified, lymph nodes of inguinal region and lower limb C82.26 Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes C82.27 Follicular lymphoma grade III, unspecified, spleen C82.28 Follicular lymphoma grade III, unspecified, lymph nodes of multiple sites C82.29 Follicular lymphoma grade III, unspecified, extranodal and solid organ sites C82.30 Follicular lymphoma grade IIIa, unspecified site C82.31 Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck C82.32 Follicular lymphoma grade IIIa, intrathoracic lymph nodes C82.33 Follicular lymphoma grade IIIa, intra-abdominal lymph nodes C82.34 Follicular lymphoma grade IIIa, lymph nodes of axilla and upper limb C82.35 Follicular lymphoma grade IIIa, lymph nodes of inguinal region and lower limb C82.36 Follicular lymphoma grade IIIa, intrapelvic lymph nodes C82.37 Follicular lymphoma grade IIIa, spleen C82.38 Follicular lymphoma grade IIIa, lymph nodes of multiple sites C82.39 Follicular lymphoma grade IIIa, extranodal and solid organ sites C82.40 Follicular lymphoma grade IIIb, unspecified site C82.41 Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck C82.42 Follicular lymphoma grade IIIb, intrathoracic lymph nodes C82.43 Follicular lymphoma grade IIIb, intra-abdominal lymph nodes C82.44 Follicular lymphoma grade IIIb, lymph nodes of axilla and upper limb C82.45 Follicular lymphoma grade IIIb, lymph nodes of inguinal region and lower limb C82.46 Follicular lymphoma grade IIIb, intrapelvic lymph nodes C82.47 Follicular lymphoma grade IIIb, spleen C82.48 Follicular lymphoma grade IIIb, lymph nodes of multiple sites C82.49 Follicular lymphoma grade IIIb, extranodal and solid organ sites C82.50 Diffuse follicle center lymphoma, unspecified site

11 Page 10 of 23 C82.51 Diffuse follicle center lymphoma, lymph nodes of head, face, and neck C82.52 Diffuse follicle center lymphoma, intrathoracic lymph nodes C82.53 Diffuse follicle center lymphoma, intra-abdominal lymph nodes C82.54 Diffuse follicle center lymphoma, lymph nodes of axilla and upper limb C82.55 Diffuse follicle center lymphoma, lymph nodes of inguinal region and lower limb C82.56 Diffuse follicle center lymphoma, intrapelvic lymph nodes C82.57 Diffuse follicle center lymphoma, spleen C82.58 Diffuse follicle center lymphoma, lymph nodes of multiple sites C82.59 Diffuse follicle center lymphoma, extranodal and solid organ sites C82.60 Cutaneous follicle center lymphoma, unspecified site C82.61 Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck C82.62 Cutaneous follicle center lymphoma, intrathoracic lymph nodes C82.63 Cutaneous follicle center lymphoma, intra-abdominal lymph nodes C82.64 Cutaneous follicle center lymphoma, lymph nodes of axilla and upper limb C82.65 Cutaneous follicle center lymphoma, lymph nodes of inguinal region and lower limb C82.66 Cutaneous follicle center lymphoma, intrapelvic lymph nodes C82.67 Cutaneous follicle center lymphoma, spleen C82.68 Cutaneous follicle center lymphoma, lymph nodes of multiple sites C82.69 Cutaneous follicle center lymphoma, extranodal and solid organ sites C82.80 Other types of follicular lymphoma, unspecified site C82.81 Other types of follicular lymphoma, lymph nodes of head, face, and neck C82.82 Other types of follicular lymphoma, intrathoracic lymph nodes C82.83 Other types of follicular lymphoma, intra-abdominal lymph nodes C82.84 Other types of follicular lymphoma, lymph nodes of axilla and upper limb C82.85 Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb C82.86 Other types of follicular lymphoma, intrapelvic lymph nodes C82.87 Other types of follicular lymphoma, spleen C82.88 Other types of follicular lymphoma, lymph nodes of multiple sites C82.89 Other types of follicular lymphoma, extranodal and solid organ sites C82.90 Follicular lymphoma, unspecified, unspecified site C82.91 Follicular lymphoma, unspecified, lymph nodes of head, face, and neck C82.92 Follicular lymphoma, unspecified, intrathoracic lymph nodes C82.93 Follicular lymphoma, unspecified, intra-abdominal lymph nodes C82.94 Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb C82.95 Follicular lymphoma, unspecified, lymph nodes of inguinal region and lower limb C82.96 Follicular lymphoma, unspecified, intrapelvic lymph nodes C82.97 Follicular lymphoma, unspecified, spleen

12 Page 11 of 23 C82.98 Follicular lymphoma, unspecified, lymph nodes of multiple sites C82.99 Follicular lymphoma, unspecified, extranodal and solid organ sites C83.00 Small cell B-cell lymphoma, unspecified site C83.01 Small cell B-cell lymphoma, lymph nodes of head, face, and neck C83.02 Small cell B-cell lymphoma, intrathoracic lymph nodes C83.03 Small cell B-cell lymphoma, intra-abdominal lymph nodes C83.04 Small cell B-cell lymphoma, lymph nodes of axilla and upper limb C83.05 Small cell B-cell lymphoma, lymph nodes of inguinal region and lower limb C83.06 Small cell B-cell lymphoma, intrapelvic lymph nodes C83.07 Small cell B-cell lymphoma, spleen C83.08 Small cell B-cell lymphoma, lymph nodes of multiple sites C83.09 Small cell B-cell lymphoma, extranodal and solid organ sites C83.10 Mantle cell lymphoma, unspecified site C83.11 Mantle cell lymphoma, lymph nodes of head, face, and neck C83.12 Mantle cell lymphoma, intrathoracic lymph nodes C83.13 Mantle cell lymphoma, intra-abdominal lymph nodes C83.14 Mantle cell lymphoma, lymph nodes of axilla and upper limb C83.15 Mantle cell lymphoma, lymph nodes of inguinal region and lower limb C83.16 Mantle cell lymphoma, intrapelvic lymph nodes C83.17 Mantle cell lymphoma, spleen C83.18 Mantle cell lymphoma, lymph nodes of multiple sites C83.19 Mantle cell lymphoma, extranodal and solid organ sites C83.30 Diffuse large B-cell lymphoma, unspecified site C83.31 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck C83.32 Diffuse large B-cell lymphoma, intrathoracic lymph nodes C83.33 Diffuse large B-cell lymphoma, intra-abdominal lymph nodes C83.34 Diffuse large B-cell lymphoma, lymph nodes of axilla and upper limb C83.35 Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb C83.36 Diffuse large B-cell lymphoma, intrapelvic lymph nodes C83.37 Diffuse large B-cell lymphoma, spleen C83.38 Diffuse large B-cell lymphoma, lymph nodes of multiple sites C83.39 Diffuse large B-cell lymphoma, extranodal and solid organ sites C83.50 Lymphoblastic (diffuse) lymphoma, unspecified site C83.51 Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck C83.52 Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes C83.53 Lymphoblastic (diffuse) lymphoma, intra-abdominal lymph nodes C83.54 Lymphoblastic (diffuse) lymphoma, lymph nodes of axilla and upper limb C83.55 Lymphoblastic (diffuse) lymphoma, lymph nodes of inguinal region and lower limb

13 Page 12 of 23 C83.56 Lymphoblastic (diffuse) lymphoma, intrapelvic lymph nodes C83.57 Lymphoblastic (diffuse) lymphoma, spleen C83.58 Lymphoblastic (diffuse) lymphoma, lymph nodes of multiple sites C83.59 Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites C83.70 Burkitt lymphoma, unspecified site C83.71 Burkitt lymphoma, lymph nodes of head, face, and neck C83.72 Burkitt lymphoma, intrathoracic lymph nodes C83.73 Burkitt lymphoma, intra-abdominal lymph nodes C83.74 Burkitt lymphoma, lymph nodes of axilla and upper limb C83.75 Burkitt lymphoma, lymph nodes of inguinal region and lower limb C83.76 Burkitt lymphoma, intrapelvic lymph nodes C83.77 Burkitt lymphoma, spleen C83.78 Burkitt lymphoma, lymph nodes of multiple sites C83.79 Burkitt lymphoma, extranodal and solid organ sites C83.80 Other non-follicular lymphoma, unspecified site C83.81 Other non-follicular lymphoma, lymph nodes of head, face, and neck C83.82 Other non-follicular lymphoma, intrathoracic lymph nodes C83.83 Other non-follicular lymphoma, intra-abdominal lymph nodes C83.84 Other non-follicular lymphoma, lymph nodes of axilla and upper limb C83.85 Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb C83.86 Other non-follicular lymphoma, intrapelvic lymph nodes C83.87 Other non-follicular lymphoma, spleen C83.88 Other non-follicular lymphoma, lymph nodes of multiple sites C83.89 Other non-follicular lymphoma, extranodal and solid organ sites C83.90 Non-follicular (diffuse) lymphoma, unspecified, unspecified site C83.91 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of head, face, and neck C83.92 Non-follicular (diffuse) lymphoma, unspecified, intrathoracic lymph nodes C83.93 Non-follicular (diffuse) lymphoma, unspecified, intra-abdominal lymph nodes C83.94 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of axilla and upper limb C83.95 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of inguinal region and lower limb C83.96 Non-follicular (diffuse) lymphoma, unspecified, intrapelvic lymph nodes C83.97 Non-follicular (diffuse) lymphoma, unspecified, spleen C83.98 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of multiple sites C83.99 Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites C84.60 Anaplastic large cell lymphoma, ALK-positive, unspecified site

14 Page 13 of 23 C84.61 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck C84.62 Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes C84.63 Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes C84.64 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb C84.65 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb C84.66 Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes C84.67 Anaplastic large cell lymphoma, ALK-positive, spleen C84.68 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites C84.69 Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites C84.70 Anaplastic large cell lymphoma, ALK-negative, unspecified site C84.71 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck C84.72 Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes C84.73 Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes C84.74 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb C84.75 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb C84.76 Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes C84.77 Anaplastic large cell lymphoma, ALK-negative, spleen C84.78 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites C84.79 Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites C84.90 Mature T/NK-cell lymphomas, unspecified, unspecified site C84.92 Mature T/NK-cell lymphomas, unspecified, intrathoracic lymph nodes C84.93 Mature T/NK-cell lymphomas, unspecified, intra-abdominal lymph nodes C84.94 Mature T/NK-cell lymphomas, unspecified, lymph nodes of axilla and upper limb C84.95 Mature T/NK-cell lymphomas, unspecified, lymph nodes of inguinal region and lower limb C84.96 Mature T/NK-cell lymphomas, unspecified, intrapelvic lymph nodes C84.97 Mature T/NK-cell lymphomas, unspecified, spleen C84.98 Mature T/NK-cell lymphomas, unspecified, lymph nodes of multiple sites C84.99 Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites C84.A0 C84.A1 C84.A2 C84.A3 C84.A4 Cutaneous T-cell lymphoma, unspecified, unspecified site Cutaneous T-cell lymphoma, unspecified lymph nodes of head, face, and neck Cutaneous T-cell lymphoma, unspecified, intrathoracic lymph nodes Cutaneous T-cell lymphoma, unspecified, intra-abdominal lymph nodes Cutaneous T-cell lymphoma, unspecified, lymph nodes of axilla and upper limb

15 Page 14 of 23 C84.A5 C84.A6 C84.A7 C84.A8 C84.A9 C84.Z0 C84.Z1 C84.Z2 C84.Z3 C84.Z4 C84.Z5 C84.Z6 C84.Z7 C84.Z8 C84.Z9 Cutaneous T-cell lymphoma, unspecified, lymph nodes of inguinal region and lower limb Cutaneous T-cell lymphoma, unspecified, intrapelvic lymph nodes Cutaneous T-cell lymphoma, unspecified, spleen Cutaneous T-cell lymphoma, unspecified, lymph nodes of multiple sites Cutaneous T-cell lymphoma, unspecified, extranodal and solid organ sites Other mature T/NK-cell lymphomas, unspecified site Other mature T/NK-cell lymphomas, lymph nodes of head, face, and neck Other mature T/NK-cell lymphomas, intrathoracic lymph nodes Other mature T/NK-cell lymphomas, intra-abdominal lymph nodes Other mature T/NK-cell lymphomas, lymph nodes of axilla and upper limb Other mature T/NK-cell lymphomas, lymph nodes of inguinal region and lower limb Other mature T/NK-cell lymphomas, intrapelvic lymph nodes Other mature T/NK-cell lymphomas, spleen Other mature T/NK-cell lymphomas, lymph nodes of multiple sites Other mature T/NK-cell lymphomas, extranodal and solid organ sites C85.10 Unspecified B-cell lymphoma, unspecified site C85.11 Unspecified B-cell lymphoma, lymph nodes of head, face, and neck C85.12 Unspecified B-cell lymphoma, intrathoracic lymph nodes C85.13 Unspecified B-cell lymphoma, intra-abdominal lymph nodes C85.14 Unspecified B-cell lymphoma, lymph nodes of axilla and upper limb C85.15 Unspecified B-cell lymphoma, lymph nodes of inguinal region and lower limb C85.16 Unspecified B-cell lymphoma, intrapelvic lymph nodes C85.17 Unspecified B-cell lymphoma, spleen C85.18 Unspecified B-cell lymphoma, lymph nodes of multiple sites C85.19 Unspecified B-cell lymphoma, extranodal and solid organ sites C85.20 Mediastinal (thymic) large B-cell lymphoma, unspecified site C85.21 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck C85.22 Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes C85.23 Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes C85.24 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of axilla and upper limb C85.25 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of inguinal region and lower limb C85.26 Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes C85.27 Mediastinal (thymic) large B-cell lymphoma, spleen C85.28 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of multiple sites C85.29 Mediastinal (thymic) large B-cell lymphoma, extranodal and solid organ sites C85.80 Other specified types of non-hodgkin lymphoma, unspecified site

16 Page 15 of 23 C85.81 Other specified types of non-hodgkin lymphoma, lymph nodes of head, face, and neck C85.82 Other specified types of non-hodgkin lymphoma, intrathoracic lymph nodes C85.83 Other specified types of non-hodgkin lymphoma, intra-abdominal lymph nodes C85.84 Other specified types of non-hodgkin lymphoma, lymph nodes of axilla and upper limb C85.85 Other specified types of non-hodgkin lymphoma, lymph nodes of inguinal region and lower limb C85.86 Other specified types of non-hodgkin lymphoma, intrapelvic lymph nodes C85.87 Other specified types of non-hodgkin lymphoma, spleen C85.88 Other specified types of non-hodgkin lymphoma, lymph nodes of multiple sites C85.89 Other specified types of non-hodgkin lymphoma, extranodal and solid organ sites C85.90 Non-Hodgkin lymphoma, unspecified, unspecified site C85.91 Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck C85.92 Non-Hodgkin lymphoma, unspecified, intrathoracic lymph nodes C85.93 Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes C85.94 Non-Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb C85.95 Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb C85.96 Non-Hodgkin lymphoma, unspecified, intrapelvic lymph nodes C85.97 Non-Hodgkin lymphoma, unspecified, spleen C85.98 Non-Hodgkin lymphoma, unspecified, lymph nodes of multiple sites C85.99 Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites C86.0 Extranodal NK/T-cell lymphoma, nasal type C86.1 Hepatosplenic T-cell lymphoma C86.2 Enteropathy-type (intestinal) T-cell lymphoma C86.3 Subcutaneous panniculitis-like T-cell lymphoma C86.4 Blastic NK-cell lymphoma C86.5 Angioimmunoblastic T-cell lymphoma C86.6 Primary cutaneous CD30-positive T-cell proliferations C88.0 Waldenstrom macroglobulinemia C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] C91.00 Acute lymphoblastic leukemia not having achieved remission C91.01 Acute lymphoblastic leukemia, in remission C91.02 Acute lymphoblastic leukemia, in relapse C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission C91.11 Chronic lymphocytic leukemia of B-cell type in remission C91.12 Chronic lymphocytic leukemia of B-cell type in relapse C91.40 Hairy cell leukemia not having achieved remission

17 Page 16 of 23 C91.41 Hairy cell leukemia, in remission C91.42 Hairy cell leukemia, in relapse C96.4 Sarcoma of dendritic cells (accessory cells) C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified C96.Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue D59.0 Drug-induced autoimmune hemolytic anemia D59.1 Other autoimmune hemolytic anemias D69.3 Immune thrombocytopenic purpura D69.41 Evans syndrome D69.42 Congenital and hereditary thrombocytopenia purpura D69.49 Other primary thrombocytopenia G35 Multiple sclerosis G36.0 Neuromyelitis optica [Devic] G37.0 Diffuse sclerosis of central nervous system G37.5 Concentric sclerosis [Balo] of central nervous system G60.8 Other hereditary and idiopathic neuropathies G61.89 Other inflammatory polyneuropathies G62.89 Other specified polyneuropathies G64 Other disorders of peripheral nervous system G70.00 Myasthenia gravis without (acute) exacerbation G70.01 Myasthenia gravis with (acute) exacerbation M Felty's syndrome, right shoulder M Felty's syndrome, left shoulder M Felty's syndrome, right elbow M Felty's syndrome, left elbow M Felty's syndrome, right wrist M Felty's syndrome, left wrist M Felty's syndrome, right hand M Felty's syndrome, left hand M Felty's syndrome, right hip M Felty's syndrome, left hip M Felty's syndrome, right knee M Felty's syndrome, left knee M Felty's syndrome, right ankle and foot M Felty's syndrome, left ankle and foot M05.09 Felty's syndrome, multiple sites M Rheumatoid vasculitis with rheumatoid arthritis of right shoulder M Rheumatoid vasculitis with rheumatoid arthritis of left shoulder

18 Page 17 of 23 M Rheumatoid vasculitis with rheumatoid arthritis of right elbow M Rheumatoid vasculitis with rheumatoid arthritis of left elbow M Rheumatoid vasculitis with rheumatoid arthritis of right wrist M Rheumatoid vasculitis with rheumatoid arthritis of left wrist M Rheumatoid vasculitis with rheumatoid arthritis of right hand M Rheumatoid vasculitis with rheumatoid arthritis of left hand M Rheumatoid vasculitis with rheumatoid arthritis of right hip M Rheumatoid vasculitis with rheumatoid arthritis of left hip M Rheumatoid vasculitis with rheumatoid arthritis of right knee M Rheumatoid vasculitis with rheumatoid arthritis of left knee M Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot M Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot M05.29 Rheumatoid vasculitis with rheumatoid arthritis of multiple sites M05.30 Rheumatoid heart disease with rheumatoid arthritis of unspecified site M Rheumatoid heart disease with rheumatoid arthritis of left shoulder M Rheumatoid heart disease with rheumatoid arthritis of right elbow M Rheumatoid heart disease with rheumatoid arthritis of left elbow M Rheumatoid heart disease with rheumatoid arthritis of right wrist M Rheumatoid heart disease with rheumatoid arthritis of left wrist M Rheumatoid heart disease with rheumatoid arthritis of right hand M Rheumatoid heart disease with rheumatoid arthritis of left hand M Rheumatoid heart disease with rheumatoid arthritis of right hip M Rheumatoid heart disease with rheumatoid arthritis of left hip M Rheumatoid heart disease with rheumatoid arthritis of right knee M Rheumatoid heart disease with rheumatoid arthritis of left knee M Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot M Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot M05.39 Rheumatoid heart disease with rheumatoid arthritis of multiple sites M Rheumatoid myopathy with rheumatoid arthritis of right shoulder M Rheumatoid myopathy with rheumatoid arthritis of left shoulder M Rheumatoid myopathy with rheumatoid arthritis of right elbow M Rheumatoid myopathy with rheumatoid arthritis of left elbow M Rheumatoid myopathy with rheumatoid arthritis of right wrist M Rheumatoid myopathy with rheumatoid arthritis of left wrist M Rheumatoid myopathy with rheumatoid arthritis of right hand M Rheumatoid myopathy with rheumatoid arthritis of left hand M Rheumatoid myopathy with rheumatoid arthritis of right hip M Rheumatoid myopathy with rheumatoid arthritis of left hip M Rheumatoid myopathy with rheumatoid arthritis of right knee

19 Page 18 of 23 M Rheumatoid myopathy with rheumatoid arthritis of left knee M Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot M Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites M Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder M Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder M Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow M Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow M Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist M Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist M Rheumatoid polyneuropathy with rheumatoid arthritis of right hand M Rheumatoid polyneuropathy with rheumatoid arthritis of left hand M Rheumatoid polyneuropathy with rheumatoid arthritis of right hip M Rheumatoid polyneuropathy with rheumatoid arthritis of left hip M Rheumatoid polyneuropathy with rheumatoid arthritis of right knee M Rheumatoid polyneuropathy with rheumatoid arthritis of left knee M Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot M Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites M Rheumatoid arthritis of right shoulder with involvement of other organs and M Rheumatoid arthritis of left shoulder with involvement of other organs and M Rheumatoid arthritis of right elbow with involvement of other organs and M Rheumatoid arthritis of left elbow with involvement of other organs and M Rheumatoid arthritis of right wrist with involvement of other organs and M Rheumatoid arthritis of left wrist with involvement of other organs and M Rheumatoid arthritis of right hand with involvement of other organs and M Rheumatoid arthritis of left hand with involvement of other organs and M Rheumatoid arthritis of right hip with involvement of other organs and M Rheumatoid arthritis of left hip with involvement of other organs and M Rheumatoid arthritis of right knee with involvement of other organs and M Rheumatoid arthritis of left knee with involvement of other organs and M Rheumatoid arthritis of right ankle and foot with involvement of other organs and

20 Page 19 of 23 M Rheumatoid arthritis of left ankle and foot with involvement of other organs and M05.69 Rheumatoid arthritis of multiple sites with involvement of other organs and M Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or involvement M Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or involvement M Rheumatoid arthritis with rheumatoid factor of right elbow without organ or involvement M Rheumatoid arthritis with rheumatoid factor of left elbow without organ or involvement M Rheumatoid arthritis with rheumatoid factor of right wrist without organ or involvement M Rheumatoid arthritis with rheumatoid factor of left wrist without organ or involvement M Rheumatoid arthritis with rheumatoid factor of right hand without organ or involvement M Rheumatoid arthritis with rheumatoid factor of left hand without organ or involvement M Rheumatoid arthritis with rheumatoid factor of right hip without organ or involvement M Rheumatoid arthritis with rheumatoid factor of left hip without organ or involvement M Rheumatoid arthritis with rheumatoid factor of right knee without organ or involvement M Rheumatoid arthritis with rheumatoid factor of left knee without organ or involvement M Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or involvement M Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or involvement M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or involvement M Other rheumatoid arthritis with rheumatoid factor of right shoulder M Other rheumatoid arthritis with rheumatoid factor of left shoulder M Other rheumatoid arthritis with rheumatoid factor of right elbow M Other rheumatoid arthritis with rheumatoid factor of left elbow M Other rheumatoid arthritis with rheumatoid factor of right wrist M Other rheumatoid arthritis with rheumatoid factor of left wrist M Other rheumatoid arthritis with rheumatoid factor of right hand M Other rheumatoid arthritis with rheumatoid factor of left hand M Other rheumatoid arthritis with rheumatoid factor of right hip M Other rheumatoid arthritis with rheumatoid factor of left hip M Other rheumatoid arthritis with rheumatoid factor of right knee M Other rheumatoid arthritis with rheumatoid factor of left knee M Other rheumatoid arthritis with rheumatoid factor of right ankle and foot

21 Page 20 of 23 M Other rheumatoid arthritis with rheumatoid factor of left ankle and foot M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified M Rheumatoid arthritis without rheumatoid factor, right shoulder M Rheumatoid arthritis without rheumatoid factor, left shoulder M Rheumatoid arthritis without rheumatoid factor, right elbow M Rheumatoid arthritis without rheumatoid factor, left elbow M Rheumatoid arthritis without rheumatoid factor, right wrist M Rheumatoid arthritis without rheumatoid factor, left wrist M Rheumatoid arthritis without rheumatoid factor, right hand M Rheumatoid arthritis without rheumatoid factor, left hand M Rheumatoid arthritis without rheumatoid factor, right hip M Rheumatoid arthritis without rheumatoid factor, left hip M Rheumatoid arthritis without rheumatoid factor, right knee M Rheumatoid arthritis without rheumatoid factor, left knee M Rheumatoid arthritis without rheumatoid factor, right ankle and foot M Rheumatoid arthritis without rheumatoid factor, left ankle and foot M06.08 Rheumatoid arthritis without rheumatoid factor, vertebrae M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites M06.1 Adult-onset Still's disease M Rheumatoid bursitis, right shoulder M Rheumatoid bursitis, left shoulder M Rheumatoid bursitis, right elbow M Rheumatoid bursitis, left elbow M Rheumatoid bursitis, right wrist M Rheumatoid bursitis, left wrist M Rheumatoid bursitis, right hand M Rheumatoid bursitis, left hand M Rheumatoid bursitis, right hip M Rheumatoid bursitis, left hip M Rheumatoid bursitis, right knee M Rheumatoid bursitis, left knee M Rheumatoid bursitis, right ankle and foot M Rheumatoid bursitis, left ankle and foot M06.28 Rheumatoid bursitis, vertebrae M06.29 Rheumatoid bursitis, multiple sites M Rheumatoid nodule, right shoulder M Rheumatoid nodule, left shoulder M Rheumatoid nodule, right elbow

22 Page 21 of 23 M Rheumatoid nodule, left elbow M Rheumatoid nodule, right wrist M Rheumatoid nodule, left wrist M Rheumatoid nodule, right hand M Rheumatoid nodule, left hand M Rheumatoid nodule, right hip M Rheumatoid nodule, left hip M Rheumatoid nodule, right knee M Rheumatoid nodule, left knee M Rheumatoid nodule, right ankle and foot M Rheumatoid nodule, left ankle and foot M06.38 Rheumatoid nodule, vertebrae M06.39 Rheumatoid nodule, multiple sites M Other specified rheumatoid arthritis, right shoulder M Other specified rheumatoid arthritis, left shoulder M Other specified rheumatoid arthritis, right elbow M Other specified rheumatoid arthritis, left elbow M Other specified rheumatoid arthritis, right wrist M Other specified rheumatoid arthritis, left wrist M Other specified rheumatoid arthritis, right hand M Other specified rheumatoid arthritis, left hand M Other specified rheumatoid arthritis, right hip M Other specified rheumatoid arthritis, left hip M Other specified rheumatoid arthritis, right knee M Other specified rheumatoid arthritis, left knee M Other specified rheumatoid arthritis, right ankle and foot M Other specified rheumatoid arthritis, left ankle and foot M06.88 Other specified rheumatoid arthritis, vertebrae M06.89 Other specified rheumatoid arthritis, multiple sites M06.9 Rheumatoid arthritis, unspecified M30.0 Polyarteritis nodosa M30.1 Polyarteritis with lung involvement [Churg-Strauss] M30.2 Juvenile polyarteritis M30.8 Other conditions related to polyarteritis nodosa M31.1 Thrombotic microangiopathy M31.30 Wegener's granulomatosis without renal involvement M31.31 Wegener's granulomatosis with renal involvement M31.7 Microscopic polyangiitis M33.20 Polymyositis, organ involvement unspecified

23 Page 22 of 23 M33.21 Polymyositis with respiratory involvement M33.22 Polymyositis with myopathy M33.29 Polymyositis with other organ involvement M35.00 Sicca syndrome, unspecified M35.01 Sicca syndrome with keratoconjunctivitis M35.02 Sicca syndrome with lung involvement M35.03 Sicca syndrome with myopathy M35.04 Sicca syndrome with tubulo-interstitial nephropathy M35.09 Sicca syndrome with other organ involvement ICD-10 Codes that DO NOT Support Medical Necessity Note: Performance is optimized by using code ranges. Additional ICD- 10 Information Associated Documents Attachments There are no attachments for this LCD Related Local Coverage Documents Related National Coverage Documents All Versions This LCD version has no Related Local Coverage Documents. This LCD version has no Related National Coverage Documents. Version 2 - Updated on 04/01/ :55:27 with effective dates 10/01/ N/A (Approved). Version 1 - Updated on 03/31/ :19:42, by Tiffany Stamps, with effective dates 10/01/ N/A. Additional Information Contractor Only Notes Keywords Rituximab Saved By Antonietta Sculimbrene Saved On 04/01/ :55:27 THIS IS A PROPOSED/DRAFT LCD Close