Colony Stimulating Factors: Neupogen (filgrastim), Neulasta (pegfilgrastim), Leukine (sargramostim), Granix (tbo-filgrastim)

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1 Neupogen (filgrastim), Neulasta (sargramostim), Granix (tbo-filgrastim) Date of Origin: 10/17/2008 Dates Reviewed: 6/17/2009, 12/22/2009, 06/15/2010/ 7/20/2010, 09/2010, 12/2010, 03/2011, 06/2011, 09/2011, 12/2011, 03/2012, 6/19/2012, 09/06/2012, 12/06/2012, 03/07/2013, 06/06/2013, 09/05/2013, 12/05/2013, 03/25/2014 Prior Auth Available: Post-Service edit: The medical necessity criteria was developed by ICORE Healthcare for the purpose of making clinical review determinations for requests for medications commonly used in various diseases. The clinical disciplines of oncology, hematology, rheumatology, neurology, internal medicine, pharmacy and nursing were consulted as part of the criteria development. The development followed an extensive literature search pertaining to established clinical guidelines and accepted prescribing patterns for each individual drug. The indications for the medications are consistent with FDA approved indications, CMS coverage guidelines, National Comprehensive Cancer Network (NCCN) guidelines and/or other published peer reviewed research literature. I. Medication Description: Colony stimulating factors (CSFs) act on hematopoietic cells by binding to specific cell surface receptors thereby stimulating proliferation, differentiation, commitment, and end cell functional activation. CSFs are biosynthetic products that stimulate the development of white blood cells such as neutrophils and macrophages (infection fighting cells). Neutropenia is defined as an absolute neutrophil count (ANC) of less than 1500/microL. The ANC is equal to the product of the white blood cell count (WBC) and the fraction of polymorphonuclear cells (PMNs) and band forms: ANC = WBC (cells/microl) x percent (PMNs + bands) 100 Absolute neutrophil count/microl Risk management >1500 None No significant risk of infection; fever can be managed on an outpatient basis Some risk of infection; fever can occasionally be managed on an outpatient basis <500 Significant risk of infection; fever should always be managed on an inpatient basis with parenteral antibiotics; few clinical signs of infection <200 Very significant risk of infection; fever should always be managed on an inpatient basis with parenteral antibiotics; few or no clinical signs of infection Fever in a neutropenic patient is usually defined as a single temperature >38.3⁰C (101.3⁰F), or a temperature >38⁰C (100.4⁰F) sustained for more than one hour. Page 1 of 42

2 II. Length of Authorization: Coverage is provided for 4 months and may be renewed III. Review Criteria: Coverage for Leukine (sargramostim) is provided in the following conditions: Myeloid reconstitution after autologous or allogeneic Bone marrow transplant (BMT) Peripheral Blood Progenitor Cell (PBPC) mobilizaton and transplant Patient with non-myeloid malignancy o Patient is undergoing myelosuppressive chemotherapy and/or radiotherapy with an expected incidence of febrile neutropenia of 20% or greater ; OR o Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 10% or greater AND one or more of the following co-morbidities: Elderly patients (age 65 or older) History of recurrent febrile neutropenia from chemotherapy Extensive prior exposure to chemotherapy Previous exposure of pelvis, or other areas of large amounts of bone marrow, to radiation Pre-existing neutropenia (ANC 1000/mm 3 ) or bone marrow involvement with tumor Patient has a condition that can potentially increase the risk of serious infection (i.e. HIV/AIDS) Infection/open wounds Recent surgery Poor performance status Poor renal function Liver dysfunction (elevated bilirubin) Patient who experienced a neutropenic complication from a prior cycle of the same chemotherapy Acute Myeloid Leukemia (AML) following induction or consolidation chemotherapy Bone Marrow Transplantation (BMT) failure or Engraftment Delay Coverage for Granix (tbo-filgrastim) is provided in the following conditions: Patient with non-myeloid malignancy Page 2 of 42

3 o Patient is undergoing myelosuppressive chemotherapy and/or radiotherapy with an expected incidence of febrile neutropenia of 20% or greater ; OR o Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 10% or greater AND one or more of the following co-morbidities: Elderly patients (age 65 or older) History of recurrent febrile neutropenia from chemotherapy Extensive prior exposure to chemotherapy Previous exposure of pelvis, or other areas of large amounts of bone marrow, to radiation Pre-existing neutropenia (ANC 1000/mm 3 ) or bone marrow involvement with tumor Patient has a condition that can potentially increase the risk of serious infection (i.e. HIV/AIDS) Infection/open wounds Recent surgery Poor performance status Poor renal function Liver dysfunction (elevated bilirubin) Coverage for Neulasta (pegfilgrastim) is provided in the following conditions: Patient with non-myeloid malignancy o Patient is undergoing myelosuppressive chemotherapy and/or radiotherapy with an expected incidence of febrile neutropenia of 20% or greater ; OR o Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 10% or greater AND one or more of the following co-morbidities: Elderly patients (age 65 or older) History of recurrent febrile neutropenia from chemotherapy Extensive prior exposure to chemotherapy Previous exposure of pelvis, or other areas of large amounts of bone marrow, to radiation Pre-existing neutropenia (ANC 1000/mm 3 ) or bone marrow involvement with tumor Patient has a condition that can potentially increase the risk of serious infection (i.e. HIV/AIDS) Infection/open wounds Recent surgery Poor performance status Poor renal function Liver dysfunction (elevated bilirubin) o In all cases patients must weigh at least 45 kg to receive Neulasta pegfilgrastim Patient who experienced a neutropenic complication from a prior cycle of the same chemotherapy Page 3 of 42

4 Coverage for Neupogen (filgrastim) is provided in the following conditions: Bone marrow transplant (BMT) Peripheral Blood Progenitor Cell (PBPC) mobilization and transplant Patient with non-myeloid malignancy o Patient is undergoing myelosuppressive chemotherapy and/or radiotherapy with an expected incidence of febrile neutropenia of 20% or greater ; OR o Patient is undergoing myelosuppressive chemotherapy with an expected incidence of febrile neutropenia of 10% or greater AND one or more of the following co-morbidities: Elderly patients (age 65 or older) History of recurrent febrile neutropenia from chemotherapy Extensive prior exposure to chemotherapy Previous exposure of pelvis, or other areas of large amounts of bone marrow, to radiation Pre-existing neutropenia (ANC 1000/mm 3 ) or bone marrow involvement with tumor Patient has a condition that can potentially increase the risk of serious infection (i.e. HIV/AIDS) Infection/open wounds Recent surgery Poor performance status Poor renal function Liver dysfunction (elevated bilirubin) Patient who experienced a neutropenic complication from a prior cycle of the same chemotherapy Acute Myeloid Leukemia (AML) patient following induction or consolidation chemotherapy Bone Marrow Transplantation (BMT) failure or Engraftment Delay Severe chronic neutropenia (ANC<500) Myelodysplastic Syndrome FDA-labeled indication(s) expected incidence of febrile neutropenia percentages for myelosuppressive chemotherapy regimens can be found in the NCCN Myeloid Growth Factors Clinical Practice Guideline at NCCN.org. IV. Renewal Criteria: Same as initial prior authorization policy criteria Page 4 of 42

5 V. Dosage/Administration: Indication (Drug) Leukine all indications Granix Neupogen Neulasta all indications Dose 250mcg/m 2 daily for up to 14 days 5mcg/kg daily for up to 14 days 5mcg/kg daily for up to 14 days for non-bmt/pbpc indications 10mcg/kg daily for up to 14 days for BMT/PBPC/Severe Neutropenia indications Up to 6mg every 14 days Do not administer within 14 days before or 24 hours after administration of a cytotoxic chemotherapy VI. Billing/Coding Information: JCode: J2820 Leukine (Bayer) 250, 500 mcg injection: 1 billable unit = 50 mcg J Neupogen (Amgen) 300 mcg, 480 mcg injection: 1 billable unit = 1 mcg J2505 Neulasta (Amgen) 6 mg injection: 1 billable unit = 6 mg J1446 Granix (Teva) 300 mcg, 480 mcg injection: 1 billable unit = 5 mcg NDC: Leukine 250 mcg vial xx (Bayer) Leukine 500 mcg vial xx (Bayer) Neupogen 300 mcg vial xx (Amgen) Neupogen 300 mcg prefilled syringe xx (Amgen) Neupogen 480 mcg vial xx (Amgen) Neupogen 480 mcg prefilled syringe xx (Amgen) Neulasta 6 mg prefilled syringe xx (Amgen) Granix 300 mcg prefilled syringe xx (Teva) Granix 400 mcg prefilled syringe xx (Teva) Max Units (per dose and over time): Leukine (J2820) Male 10 billable units per day Female 10 billable units per day Neupogen (J1442) Severe Chronic Neutropenia: Male 1380 billable units per day Female 1200 billable units per day Page 5 of 42

6 BMT or PBPC: Male Female 1200 billable units per day 960 billable units per day All other indications: Male 600 billable units per day Female 480 billable units per day Granix (J1446) Male Female 120 billable units per day 96 billable units per day Neulasta (J2505) Male 1 billable unit per 14 days Female 1 billable unit per 14 days Quantity Limits Leukine 250 mcg vial: 28 vials per 14 days Leukine 500 mcg vial: 14 vials per 14 days Neupogen 300 mcg vial: 90 vials per 30 days Neupogen 300 mcg prefilled syringe: 90 syringes per 30 days Neupogen 480 mcg vial: 90 vials per 30 days Neupogen 480 mcg prefilled syringe: 90 syringes per 30 days Neulasta 6 mg prefilled syringe: 1 syringe per 14 days Granix 300 mcg: 28 syringes per 14 days Granix 480 mcg; 14 syringes per 14 days Covered Diagnosis: Leukine Drug induced neutropenia Complications of transplanted bone marrow V07.8 Other specified prophylactic or treatment measure V42.81 Bone marrow replaced by transplant V42.82 Peripheral stem cells replaced by transplant V58.11 Encounter for antineoplastic chemotherapy V66.2 Convalescence following chemotherapy Page 6 of 42

7 Granix Drug induced neutropenia V07.8 Other specified prophylactic or treatment measure V58.11 Encounter for antineoplastic chemotherapy V66.2 Convalescence following chemotherapy Neulasta Drug induced neutropenia V07.8 Other specified prophylactic or treatment measure V58.11 Encounter for antineoplastic chemotherapy V66.2 Convalescence following chemotherapy Neupogen 042 Human immunodeficiency virus (HIV) Chronic myeloid leukemia, without mention of achieving remission Low grade myelodysplastic syndrome (MDS) lesions High grade myelodysplastic syndrome lesions Myelodysplastic syndrome with 5q deletion Myelodysplastic syndrome (MDS) unspecified Other specified aplastic anemias Neutropenia, unspecified Congenital neutropenia Cyclic neutropenia Drug induced neutropenia Complications of transplanted bone marrow V07.8 Other specified prophylactic or treatment measure V42.81 Bone marrow replaced by transplant V42.82 Peripheral stem cells replaced by transplant V58.11 Encounter for antineoplastic chemotherapy V66.2 Convalescence following chemotherapy VII. Centers for Medicare and Medicaid Services (CMS): Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub ), Chapter 15, 50 Drugs and Biologicals. In addition, National Coverage Determination (NCD) and Local Coverage Determinations (LCDs) may exist and compliance with these policies is required where applicable. They can be found at: Additional indications may be covered at the discretion of the health plan. Page 7 of 42

8 Medicare Part B Covered Diagnosis Codes (applicable to existing NCD/LCD): Leukine (J2820), Neupogen (J1442), Neulasta (J2505), Granix (J1446) Jurisdiction(s): 15 NCD/LCD Document (s): L31851 ICD-9 Codes Diagnosis MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER MALIGNANT NEOPLASM OF LOWER LIP VERMILION BORDER MALIGNANT NEOPLASM OF UPPER LIP INNER ASPECT MALIGNANT NEOPLASM OF LOWER LIP INNER ASPECT MALIGNANT NEOPLASM OF LIP UNSPECIFIED INNER ASPECT MALIGNANT NEOPLASM OF COMMISSURE OF LIP MALIGNANT NEOPLASM OF OTHER SITES OF LIP MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER MALIGNANT NEOPLASM OF BASE OF TONGUE MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUE MALIGNANT NEOPLASM OF TIP AND LATERAL BORDER OF TONGUE MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE PART UNSPECIFIED MALIGNANT NEOPLASM OF JUNCTIONAL ZONE OF TONGUE MALIGNANT NEOPLASM OF LINGUAL TONSIL MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED MALIGNANT NEOPLASM OF PAROTID GLAND MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND MALIGNANT NEOPLASM OF SUBLINGUAL GLAND MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED MALIGNANT NEOPLASM OF UPPER GUM MALIGNANT NEOPLASM OF LOWER GUM MALIGNANT NEOPLASM OF OTHER SITES OF GUM MALIGNANT NEOPLASM OF GUM UNSPECIFIED MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH Page 8 of 42

9 144.9 MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED MALIGNANT NEOPLASM OF CHEEK MUCOSA MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH MALIGNANT NEOPLASM OF HARD PALATE MALIGNANT NEOPLASM OF SOFT PALATE MALIGNANT NEOPLASM OF UVULA MALIGNANT NEOPLASM OF PALATE UNSPECIFIED MALIGNANT NEOPLASM OF RETROMOLAR AREA MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED MALIGNANT NEOPLASM OF TONSIL MALIGNANT NEOPLASM OF TONSILLAR FOSSA MALIGNANT NEOPLASM OF TONSILLAR PILLARS (ANTERIOR) (POSTERIOR) MALIGNANT NEOPLASM OF VALLECULA EPIGLOTTICA MALIGNANT NEOPLASM OF ANTERIOR ASPECT OF EPIGLOTTIS MALIGNANT NEOPLASM OF JUNCTIONAL REGION OF OROPHARYNX MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF OROPHARYNX MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX MALIGNANT NEOPLASM OF PYRIFORM SINUS MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD HYPOPHARYNGEAL ASPECT MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED MALIGNANT NEOPLASM OF WALDEYER'S RING Page 9 of 42

10 149.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS MALIGNANT NEOPLASM OF THORACIC ESOPHAGUS MALIGNANT NEOPLASM OF ABDOMINAL ESOPHAGUS MALIGNANT NEOPLASM OF UPPER THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF MIDDLE THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE MALIGNANT NEOPLASM OF CARDIA MALIGNANT NEOPLASM OF PYLORUS MALIGNANT NEOPLASM OF PYLORIC ANTRUM MALIGNANT NEOPLASM OF FUNDUS OF STOMACH MALIGNANT NEOPLASM OF BODY OF STOMACH MALIGNANT NEOPLASM OF LESSER CURVATURE OF STOMACH UNSPECIFIED MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE MALIGNANT NEOPLASM OF DUODENUM MALIGNANT NEOPLASM OF JEJUNUM MALIGNANT NEOPLASM OF ILEUM MALIGNANT NEOPLASM OF MECKEL'S DIVERTICULUM MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE MALIGNANT NEOPLASM OF HEPATIC FLEXURE MALIGNANT NEOPLASM OF TRANSVERSE COLON MALIGNANT NEOPLASM OF DESCENDING COLON MALIGNANT NEOPLASM OF SIGMOID COLON MALIGNANT NEOPLASM OF CECUM MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS MALIGNANT NEOPLASM OF ASCENDING COLON Page 10 of 42

11 153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION MALIGNANT NEOPLASM OF RECTUM MALIGNANT NEOPLASM OF ANAL CANAL MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS MALIGNANT NEOPLASM OF LIVER PRIMARY MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY MALIGNANT NEOPLASM OF GALLBLADDER MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS MALIGNANT NEOPLASM OF AMPULLA OF VATER MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF GALLBLADDER AND EXTRAHEPATIC BILE DUCTS MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE MALIGNANT NEOPLASM OF HEAD OF PANCREAS MALIGNANT NEOPLASM OF BODY OF PANCREAS MALIGNANT NEOPLASM OF TAIL OF PANCREAS MALIGNANT NEOPLASM OF PANCREATIC DUCT MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED MALIGNANT NEOPLASM OF RETROPERITONEUM MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED MALIGNANT NEOPLASM OF INTESTINAL TRACT PART UNSPECIFIED MALIGNANT NEOPLASM OF SPLEEN NOT ELSEWHERE CLASSIFIED MALIGNANT NEOPLASM OF OTHER SITES OF DIGESTIVE SYSTEM AND INTRA-ABDOMINAL ORGANS MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM MALIGNANT NEOPLASM OF NASAL CAVITIES Page 11 of 42

12 160.1 MALIGNANT NEOPLASM OF AUDITORY TUBE MIDDLE EAR AND MASTOID AIR CELLS MALIGNANT NEOPLASM OF MAXILLARY SINUS MALIGNANT NEOPLASM OF ETHMOIDAL SINUS MALIGNANT NEOPLASM OF FRONTAL SINUS MALIGNANT NEOPLASM OF SPHENOIDAL SINUS MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED MALIGNANT NEOPLASM OF GLOTTIS MALIGNANT NEOPLASM OF SUPRAGLOTTIS MALIGNANT NEOPLASM OF SUBGLOTTIS MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED MALIGNANT NEOPLASM OF TRACHEA MALIGNANT NEOPLASM OF MAIN BRONCHUS MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED MALIGNANT NEOPLASM OF PARIETAL PLEURA MALIGNANT NEOPLASM OF VISCERAL PLEURA MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PLEURA MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED MALIGNANT NEOPLASM OF THYMUS MALIGNANT NEOPLASM OF HEART MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM MALIGNANT NEOPLASM OF OTHER PARTS OF MEDIASTINUM MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED MALIGNANT NEOPLASM OF UPPER RESPIRATORY TRACT PART UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE RESPIRATORY SYSTEM AND INTRATHORACIC ORGANS MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE RESPIRATORY SYSTEM Page 12 of 42

13 170.0 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE MALIGNANT NEOPLASM OF MANDIBLE MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX MALIGNANT NEOPLASM OF RIBS STERNUM AND CLAVICLE MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND COCCYX MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF THORAX MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF ABDOMEN MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF PELVIS MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF TRUNK UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CONNECTIVE AND OTHER SOFT TISSUE MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED MALIGNANT MELANOMA OF SKIN OF LIP MALIGNANT MELANOMA OF SKIN OF EYELID INCLUDING CANTHUS MALIGNANT MELANOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE MALIGNANT MELANOMA OF SKIN OF SCALP AND NECK MALIGNANT MELANOMA OF SKIN OF TRUNK EXCEPT SCROTUM MALIGNANT MELANOMA OF SKIN OF UPPER LIMB INCLUDING SHOULDER Page 13 of 42

14 172.7 MALIGNANT MELANOMA OF SKIN OF LOWER LIMB INCLUDING HIP MALIGNANT MELANOMA OF OTHER SPECIFIED SITES OF SKIN MELANOMA OF SKIN SITE UNSPECIFIED MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST KAPOSI'S SARCOMA SKIN KAPOSI'S SARCOMA SOFT TISSUE KAPOSI'S SARCOMA PALATE KAPOSI'S SARCOMA GASTROINTESTINAL SITES KAPOSI'S SARCOMA LUNG KAPOSI'S SARCOMA LYMPH NODES KAPOSI'S SARCOMA OTHER SPECIFIED SITES KAPOSI'S SARCOMA UNSPECIFIED SITE 179 MALIGNANT NEOPLASM OF UTERUS-PART UNS MALIGNANT NEOPLASM OF ENDOCERVIX MALIGNANT NEOPLASM OF EXOCERVIX MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CERVIX MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIED SITE 181 MALIGNANT NEOPLASM OF PLACENTA MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS MALIGNANT NEOPLASM OF ISTHMUS MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS Page 14 of 42

15 183.0 MALIGNANT NEOPLASM OF OVARY MALIGNANT NEOPLASM OF FALLOPIAN TUBE MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS MALIGNANT NEOPLASM OF PARAMETRIUM MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE MALIGNANT NEOPLASM OF VAGINA MALIGNANT NEOPLASM OF LABIA MAJORA MALIGNANT NEOPLASM OF LABIA MINORA MALIGNANT NEOPLASM OF CLITORIS MALIGNANT NEOPLASM OF VULVA UNSPECIFIED SITE MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE GENITAL ORGANS MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED 185 MALIGNANT NEOPLASM OF PROSTATE MALIGNANT NEOPLASM OF UNDESCENDED TESTIS MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED TESTIS MALIGNANT NEOPLASM OF PREPUCE MALIGNANT NEOPLASM OF GLANS PENIS MALIGNANT NEOPLASM OF BODY OF PENIS MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED MALIGNANT NEOPLASM OF EPIDIDYMIS MALIGNANT NEOPLASM OF SPERMATIC CORD MALIGNANT NEOPLASM OF SCROTUM MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF MALE GENITAL ORGANS MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER MALIGNANT NEOPLASM OF BLADDER NECK MALIGNANT NEOPLASM OF URETERIC ORIFICE Page 15 of 42

16 188.7 MALIGNANT NEOPLASM OF URACHUS MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS MALIGNANT NEOPLASM OF RENAL PELVIS MALIGNANT NEOPLASM OF URETER MALIGNANT NEOPLASM OF URETHRA MALIGNANT NEOPLASM OF PARAURETHRAL GLANDS MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID MALIGNANT NEOPLASM OF ORBIT MALIGNANT NEOPLASM OF LACRIMAL GLAND MALIGNANT NEOPLASM OF CONJUNCTIVA MALIGNANT NEOPLASM OF CORNEA MALIGNANT NEOPLASM OF RETINA MALIGNANT NEOPLASM OF CHOROID MALIGNANT NEOPLASM OF LACRIMAL DUCT MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES MALIGNANT NEOPLASM OF FRONTAL LOBE MALIGNANT NEOPLASM OF TEMPORAL LOBE MALIGNANT NEOPLASM OF PARIETAL LOBE MALIGNANT NEOPLASM OF OCCIPITAL LOBE MALIGNANT NEOPLASM OF VENTRICLES MALIGNANT NEOPLASM OF CEREBELLUM NOS MALIGNANT NEOPLASM OF BRAIN STEM MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE MALIGNANT NEOPLASM OF CRANIAL NERVES MALIGNANT NEOPLASM OF CEREBRAL MENINGES MALIGNANT NEOPLASM OF SPINAL CORD MALIGNANT NEOPLASM OF SPINAL MENINGES Page 16 of 42

17 192.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM MALIGNANT NEOPLASM OF NERVOUS SYSTEM PART UNSPECIFIED 193 MALIGNANT NEOPLASM OF THYROID GLAND MALIGNANT NEOPLASM OF ADRENAL GLAND MALIGNANT NEOPLASM OF PARATHYROID GLAND MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT MALIGNANT NEOPLASM OF PINEAL GLAND MALIGNANT NEOPLASM OF CAROTID BODY MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA MALIGNANT NEOPLASM OF OTHER ENDOCRINE GLANDS AND RELATED STRUCTURES MALIGNANT NEOPLASM OF ENDOCRINE GLAND SITE UNSPECIFIED MALIGNANT NEOPLASM OF HEAD FACE AND NECK MALIGNANT NEOPLASM OF THORAX MALIGNANT NEOPLASM OF ABDOMEN MALIGNANT NEOPLASM OF PELVIS MALIGNANT NEOPLASM OF UPPER LIMB MALIGNANT NEOPLASM OF LOWER LIMB MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRA- ABDOMINAL LYMPH NODES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER LIMB SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF INGUINAL REGION AND LOWER LIMB SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRAPELVIC LYMPH NODES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF MULTIPLE SITES SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES SITE UNSPECIFIED SECONDARY MALIGNANT NEOPLASM OF LUNG SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUM Page 17 of 42

18 197.2 SECONDARY MALIGNANT NEOPLASM OF PLEURA SECONDARY MALIGNANT NEOPLASM OF OTHER RESPIRATORY ORGANS SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE INCLUDING DUODENUM SECONDARY MALIGNANT NEOPLASM OF LARGE INTESTINE AND RECTUM SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM MALIGNANT NEOPLASM OF LIVER SECONDARY SECONDARY MALIGNANT NEOPLASM OF OTHER DIGESTIVE ORGANS AND SPLEEN SECONDARY MALIGNANT NEOPLASM OF KIDNEY SECONDARY MALIGNANT NEOPLASM OF OTHER URINARY ORGANS SECONDARY MALIGNANT NEOPLASM OF SKIN SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW SECONDARY MALIGNANT NEOPLASM OF OVARY SECONDARY MALIGNANT NEOPLASM OF ADRENAL GLAND SECONDARY MALIGNANT NEOPLASM OF BREAST SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES DISSEMINATED MALIGNANT NEOPLASM OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN RETICULOSARCOMA UNSPECIFIED SITE RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES RETICULOSARCOMA INVOLVING SPLEEN RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES Page 18 of 42

19 LYMPHOSARCOMA UNSPECIFIED SITE LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK LYMPHOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES LYMPHOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES LYMPHOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB LYMPHOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB LYMPHOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES LYMPHOSARCOMA INVOLVING SPLEEN LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES BURKITT'S TUMOR OR LYMPHOMA INVOLVING SPLEEN BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK MARGINAL ZONE LYMPHOMA,INTRATHORACIC LYMPH NODES MARGINAL ZONE LYMPHOMA, INTRAABDOMINAL LYMPH NODES MARGINAL ZONE LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB MARGINAL ZONE LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MARGINAL ZONE LYMPHOMA, INTRAPELVIC LYMPH NODES MARGINAL ZONE LYMPHOMA, SPLEEN MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES Page 19 of 42

20 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES MANTLE CELL LYMPHOMA, SPLEEN MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRATHORACIC LYMPH NODES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, INTRAPELVIC LYMPH NODES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, SPLEEN PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK ANAPLASTIC LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES ANAPLASTIC LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB ANAPLASTIC LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES ANAPLASTIC LARGE CELL LYMPHOMA, SPLEEN Page 20 of 42

21 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK LARGE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES LARGE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES LARGE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB LARGE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB LARGE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES LARGE CELL LYMPHOMA, SPLEEN LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRATHORACIC LYMPH NODES OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING INTRAPELVIC LYMPH NODES OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING SPLEEN OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S PARAGRANULOMA INVOLVING INTRATHORACIC LYMPH NODES HODGKIN'S PARAGRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF AXILLA Page 21 of 42

22 AND UPPER LIMB HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB HODGKIN'S PARAGRANULOMA INVOLVING INTRAPELVIC LYMPH NODES HODGKIN'S PARAGRANULOMA INVOLVING SPLEEN HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S GRANULOMA UNSPECIFIED SITE HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S GRANULOMA INVOLVING INTRATHORACIC LYMPH NODES HODGKIN'S GRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB HODGKIN'S GRANULOMA INVOLVING INTRAPELVIC LYMPH NODES HODGKIN'S GRANULOMA INVOLVING SPLEEN HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S SARCOMA UNSPECIFIED SITE HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S SARCOMA INVOLVING INTRATHORACIC LYMPH NODES HODGKIN'S SARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB HODGKIN'S SARCOMA INVOLVING INTRAPELVIC LYMPH NODES HODGKIN'S SARCOMA INVOLVING SPLEEN HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRATHORACIC LYMPH NODES HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRA-ABDOMINAL LYMPH NODES Page 22 of 42

23 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRAPELVIC LYMPH NODES HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING SPLEEN HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRATHORACIC LYMPH NODES HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRA- ABDOMINAL LYMPH NODES HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRAPELVIC LYMPH NODES HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING SPLEEN HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRATHORACIC LYMPH NODES HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRA- ABDOMINAL LYMPH NODES HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRAPELVIC LYMPH NODES HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING SPLEEN HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE Page 23 of 42

24 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRATHORACIC LYMPH NODES HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRA- ABDOMINAL LYMPH NODES HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRAPELVIC LYMPH NODES HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING SPLEEN HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF HEAD FACE AND NECK HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRATHORACIC LYMPH NODES HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRA-ABDOMINAL LYMPH NODES HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRAPELVIC LYMPH NODES HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING SPLEEN HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES NODULAR LYMPHOMA UNSPECIFIED SITE NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES NODULAR LYMPHOMA INVOLVING SPLEEN Page 24 of 42

25 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES MYCOSIS FUNGOIDES UNSPECIFIED SITE MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF HEAD FACE AND NECK MYCOSIS FUNGOIDES INVOLVING INTRATHORACIC LYMPH NODES MYCOSIS FUNGOIDES INVOLVING INTRA-ABDOMINAL LYMPH NODES MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MYCOSIS FUNGOIDES INVOLVING INTRAPELVIC LYMPH NODES MYCOSIS FUNGOIDES INVOLVING SPLEEN MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES SEZARY'S DISEASE UNSPECIFIED SITE SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES SEZARY'S DISEASE INVOLVING SPLEEN SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE Page 25 of 42

26 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES LETTERER-SIWE DISEASE UNSPECIFIED SITE LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES LETTERER-SIWE DISEASE INVOLVING SPLEEN LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN Page 26 of 42

27 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES PERIPHERAL T CELL LYMPHOMA, SPLEEN PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER Page 27 of 42

28 LIMB OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MULTIPLE MYELOMA IN REMISSION MULTIPLE MYELOMA, IN RELAPSE PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION PLASMA CELL LEUKEMIA IN REMISSION PLASMA CELL LEUKEMIA, IN RELAPSE OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LYMPHOID LEUKEMIA ACUTE IN REMISSION ACUTE LYMPHOID LEUKEMIA, IN RELAPSE CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LYMPHOID LEUKEMIA CHRONIC IN REMISSION CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LYMPHOID LEUKEMIA SUBACUTE IN REMISSION SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTHER LYMPHOID LEUKEMIA IN REMISSION OTHER LYMPHOID LEUKEMIA, IN RELAPSE UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION Page 28 of 42

29 UNSPECIFIED LYMPHOID LEUKEMIA IN REMISSION UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MYELOID LEUKEMIA, IN RELAPSE CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHRONIC MYELOID LEUKEMIA, IN RELAPSE MALIGNANT CARCINOID TUMOR OF THE SMALL INTESTINE, UNSPECIFIED PORTION - MERKEL CELL CARCINOMA OF OTHER SITES SECONDARY NEUROENDOCRINE TUMOR, UNSPECIFIED SITE - SECONDARY NEUROENDOCRINE TUMOR OF OTHER SITES CARCINOMA IN SITU OF LIP ORAL CAVITY AND PHARYNX - NEOPLASM OF UNCERTAIN BEHAVIOR SITE UNSPECIFIED NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES ANTINEOPLASTIC CHEMOTHERAPY INDUCED ANEMIA NEUTROPENIA, UNSPECIFIED - OTHER NEUTROPENIA FELTY'S SYNDROME V42.81 BONE MARROW REPLACED BY TRANSPLANT V42.82 PERIPHERAL STEM CELLS REPLACED BY TRANSPLANT V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.12 ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION V59.3 BONE MARROW DONORS Leukine (J2820), Neupogen (J1442), Neulasta (J2505), Granix (J1446) Jurisdiction(s): 11(M) NCD/LCD Document (s): L31799 ICD-9 Codes Diagnosis MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MYELOID LEUKEMIA, IN RELAPSE CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHRONIC MYELOID LEUKEMIA, IN RELAPSE MALIGNANT CARCINOID TUMOR OF THE SMALL INTESTINE, UNSPECIFIED PORTION - MERKEL CELL CARCINOMA OF OTHER SITES SECONDARY NEUROENDOCRINE TUMOR, UNSPECIFIED SITE - SECONDARY NEUROENDOCRINE TUMOR OF OTHER SITES Page 29 of 42

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