Growth Hormone Excluding Serostim / Zorbtive

Transcription

1 Drugs Requiring Prior Authorization *RESTRICTED PHARMACY NETWORK APPLIES See Prior Authorization Forms or contact Navitus Customer Care at for details. Label Name GCN *GENOTROPIN 12 MG CARTRIDGE *GENOTROPIN MINIQUICK 0.2 MG *GENOTROPIN MINIQUICK 0.4 MG *GENOTROPIN MINIQUICK 0.8 MG *GENOTROPIN MINIQUICK 1.2 MG *GENOTROPIN MINIQUICK 1.4 MG *GENOTROPIN MINIQUICK 1.6 MG *GENOTROPIN MINIQUICK 1.8 MG *GENOTROPIN MINIQUICK 2 MG *GENOTROPIN MINIQUICK 0.6 MG *GENOTROPIN 5 MG CARTRIDGE *GENOTROPIN MINIQUICK 1 MG HUMATROPE 5 MG VIAL HUMATROPE 6 MG CARTRIDGE HUMATROPE 12 MG CARTRIDGE HUMATROPE 24 MG CARTRIDGE *NORDITROPIN NORDIFLEX 30 MG/ *NORDITROPIN FLEXPRO 5 MG/ *NORDITROPIN FLEXPRO 15 MG/ *NORDITROPIN FLEXPRO 10 MG/ NUTROPIN AQ PEN CARTRIDGE NUTROPIN AQ 20 MG/2ML PEN CART NUTROPIN AQ NUSPIN 10 INJECTOR NUTROPIN AQ NUSPIN 5 INJECTOR NUTROPIN AQ NUSPIN 20 INJECTOR OMNITROPE 5 MG/1.5 ML CRTG OMNITROPE 10 MG/1.5 ML CRTG OMNITROPE 5.8 MG VIAL SAIZEN 5 MG VIAL SAIZEN 8.8 MG CLICK EASY CARTG SAIZEN 8.8 MG VIAL TEV-TROPIN 5 MG VIAL /18/2018 1

2 Clinical Edit Criteria Logic 1. Is the client 0 to 16 (> 0 and 16) years of age? Yes (Go to # 2) No (Go to # 7) 2. Does the client have a diagnosis of growth hormone deficiency (GHD), idiopathic short stature (ISS), or small for gestational age (SGA) in the last 3 years? Yes (Go to # 6) No (Go to # 3) 3. Does the client have a diagnosis of panhypopituitarism, SHOX deficiency or Turner/Noonan/Prader-Willi syndrome in the last 3 years? Yes (Go to # 11) No (Go to # 4) 4. Does the client have a diagnosis of chronic kidney disease (CKD) in the last 3 years? Yes (Go to # 5) No (Deny) 5. Does the client have a history of a renal transplant (CPT) in the last 3 years? Yes (Deny) No (Go to #6) 6. Does the submitted documentation support the requested diagnosis? [Manual Step - NOTE: For initial requests, documentation must be from within the past 12 months. For renewal requests, documentation must be from within the past 6 months] Yes (Go to # 11) No (Deny) 7. Does the client have a diagnosis of panhypopituitarism in the last 3 years? Yes (Go to # 9) No (Go to # 8) 8. Does the client have a diagnosis of growth hormone deficiency (GHD) or idiopathic short stature (ISS) in the last 3 years? Yes (Go to # 10) No (Deny) 9. Has the client had at least 2 claims for the requested medication in the last 90 days (stable therapy)? Yes (Go to # 11) No (Go to # 10) 06/18/2018 2

3 10. Does the submitted documentation support the requested diagnosis? [Manual Step - NOTE: For initial requests, documentation must be from within the past 12 months. For renewal requests, documentation must be from within the past 6 months] Yes (Go to # 11) No (Deny) 11. Does the client have a diagnosis of active malignancy in the last 180 days? Yes (Deny) No (Go to # 12) 12. Does the client have a history of chemotherapy/radiation (CPTs) in the last 180 days? Yes (Deny) No (Go to # 13) 13. Does the client have a diagnosis of active proliferative or severe non-proliferative diabetic retinopathy in the last 365 days? Yes (Deny) No (Approve 365 days) 06/18/2018 3

4 Clinical Edit Criteria Logic Diagram Step 1: Is the client 0 to 16 (> 0 and 16) years of age? Yes Step 2: Does the client have a diagnosis of growth hormone deficiency (GHD), idiopathic short stature (ISS), or small for gestational age (SGA) in the last 3 years? No Step 3: Does the client have a diagnosis of panhypopituitarism, SHOX deficiency or Turner/Noonan/ Prader-Willi syndrome in the last 3 years? No Step 4: Does the client have a diagnosis of chronic kidney disease (CKD) in the last 3 years? No Deny No Yes Yes Yes Go to Step 7 Step 6: Does the submitted documentation support the requested diagnosis? [Manual] Yes Go to Step 11 Step 5: Does the client have a history of a renal transplant (CPT) in the last 3 years? Yes Deny No No Deny Go to Step 6 Step 7: Does the client have a diagnosis of panhypopituitarism in the last 3 years? Yes Step 9: Has the client had at least 2 claims for the requested medication in the last 90 days (stable therapy)? No Step 10: Does the submitted documentation support the requested diagnosis? [Manual] No Deny No Yes Yes Step 8: Does the client have a diagnosis of growth hormone deficiency (GHD) or idiopathic short stature (ISS) in the last 3 years? Step 11: Does the client have a diagnosis of active malignancy in the last 180 days? No Step 12: Does the client have a history of chemotherapy/radiation (CPTs) in the last 180 days? No Step 13: Does the client have a diagnosis of active proliferative or severe non-proliferative diabetic retinopathy in the last 365 days? No Approve (365 days) Yes No Yes Yes Yes Go to Step 10 Deny Deny Deny 06/18/2018 4

5 Clinical Edit Criteria Supporting Tables Step 2 (diagnosis of GHD, ISS, or SGA) Required diagnosis: 1 Look back timeframe: 3 years ICD-9 Code Description 2533 PITUITARY DWARFISM FET GROWTH RETARD WT NOS FET GROWTH RETARD <500G FET GROWTH RET G FET GROWTH RET G FET GRWTH RET G FET GRWTH RET G FET GRWTH RET G FET GRWTH RET G FET GRWTH RET G FET GROWTH RET 2500+G SHORT STATURE ICD-10 Code Description E343 SHORT STATURE DUE TO ENDOCRINE DISORDER P059 NEWBORN AFFECTED BY SLOW INTRAUTERINE GROWTH, UNSPECIFIED R6252 SHORT STATURE (CHILD) P051 NEWBORN SMALL FOR GESTATIONAL AGE P0510 P0511 P0512 P0513 P0514 P0515 P0516 P0517 P0518 P0519 NEWBORN SMALL FOR GESTATIONAL AGE UNSPECIFIED WEIGHT NEWBORN SMALL FOR GESTATIONAL AGE < 500 GRAMS NEWBORN SMALL FOR GESTATIONAL AGE, GRAMS NEWBORN SMALL FOR GESTATIONAL AGE, GRAMS NEWBORN SMALL FOR GESTATIONAL AGE, GRAMS NEWBORN SMALL FOR GESTATIONAL AGE, GRAMS NEWBORN SMALL FOR GESTATIONAL AGE, GRAMS NEWBORN SMALL FOR GESTATIONAL AGE, GRAMS NEWBORN SMALL FOR GESTATIONAL AGE, GRAMS NEWBORN SMALL FOR GESTATIONAL AGE, OTHER 06/18/2018 5

6 ICD-9 Code Step 3 (diagnosis of panhypopituitarism, SHOX deficiency or Turner/Noonan/Prader-Willi syndrome) Description 2532 PANHYPOPITUITARISM 2533 PITUITARY DWARFISM Required diagnosis: 1 Look back timeframe: 3 years 2537 IATROGENIC PITUITARY DIS 7586 TURNER S SYNDROME (GONADAL DYSGENESIS) PRADER-WILLI SYNDROME ICD-10 Code E230 E231 E893 Q871 Q960 Q961 Q962 Q963 Q964 Q968 Q969 Description HYPOPITUITARISM DRUG-INDUCED HYPOPITUITARISM POSTPROCEDURAL HYPOPITUITARISM CONGENITAL MALFORMATION SYNDROMES PREDOMINANTLY ASSOCIATED WITH SHORT STATURE KARYOTYPE 45, X KARYOTYPE 46, X ISO (XQ) KARYOTYPE 46, X WITH ABNORMAL SEX CHROMOSOME, EXCEPT ISO (XQ) MOSAICISM, 45, X/46, XX OR XY MOSAICISM, 45, X/OTHER CELL LINE(S) WITH ABNORMAL SEX CHROMOSOME OTHER VARIANTS OF TURNER'S SYNDROME TURNER'S SYNDROME, UNSPECIFIED Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years ICD-9 Code Description 585 CHRONIC RENAL FAILURE 586 RENAL FAILURE NOS 587 RENAL SCLEROSIS NOS 5810 NEPHROTIC SYN, PROLIFER 5811 EPIMEMBRANOUS NEPHRITIS 5812 MEMBRANOPROLIF NEPHROSIS 06/18/2018 6

7 ICD-9 Code Description Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years 5813 MINIMAL CHANGE NEPHROSIS 5819 NEPHROTIC SYNDROME NOS 5820 CHR PROLIFERAT NEPHRITIS 5821 CHR MEMBRANOUS NEPHRITIS 5822 CHR MEMBRANOPROLIF NEPHR 5824 CHR RAPID PROGR NEPHRIT 5829 CHRONIC NEPHRITIS NOS 5830 PROLIFERAT NEPHRITIS NOS 5831 MEMBRANOUS NEPHRITIS NOS 5832 MEMBRANOPROLIF NEPHR NOS 5834 RAPIDLY PROG NEPHRIT NOS 5836 RENAL CORT NECROSIS NOS 5837 NEPHR NOS/MEDULL NECROS 5839 NEPHRITIS NOS 5851 CHRONIC KIDNEY DISEASE, STAGE I CHRONIC KIDNEY DISEASE, STAGE II (MILD) CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED RENAL OSTEODYSTROPHY 5881 NEPHROGEN DIABETES INSIP 5888 IMPAIRED RENAL FUNCT NEC 5889 IMPAIRED RENAL FUNCT NOS ACUTE NEPHRITIS NEC NEPHROTIC SYN IN OTH DIS NEPHROTIC SYNDROME NEC CHR NEPHRITIS IN OTH DIS CHRONIC NEPHRITIS NEC NEPHRITIS NOS IN OTH DIS 06/18/2018 7

8 ICD-9 Code Description NEPHRITIS NEC ICD-10 Code B520 E0821 E0822 E0829 E0921 E0922 E0929 M3214 M3215 M3504 Description Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years PLASMODIUM MALARIAE MALARIA WITH NEPHROPATHY DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH DIABETIC NEPHROPATHY DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH DIABETIC CHRONIC KIDNEY DISEASE DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH OTHER DIABETIC KIDNEY COMPLICATION DRUG OR CHEMICAL INDUCED DIABETES MELLITUS WITH DIABETIC NEPHROPATHY DRUG OR CHEMICAL INDUCED DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE DRUG OR CHEMICAL INDUCED DIABETES MELLITUS WITH OTHER DIABETIC KIDNEY COMPLICATION GLOMERULAR DISEASE IN SYSTEMIC LUPUS ERYTHEMATOSUS TUBULO-INTERSTITIAL NEPHROPATHY IN SYSTEMIC LUPUS ERYTHEMATOSUS SICCA SYNDROME WITH TUBULO-INTERSTITIAL NEPHROPATHY N008 N020 N021 N022 N023 N024 N025 N026 N027 N028 ACUTE NEPHRITIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES RECURRENT AND PERSISTENT HEMATURIA WITH MINOR GLOMERULAR ABNORMALITY RECURRENT AND PERSISTENT HEMATURIA WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS RECURRENT AND PERSISTENT HEMATURIA WITH DENSE DEPOSIT DISEASE RECURRENT AND PERSISTENT HEMATURIA WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS RECURRENT AND PERSISTENT HEMATURIA WITH OTHER MORPHOLOGIC CHANGES 06/18/2018 8

9 Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years ICD-10 Code N029 N030 N031 N032 N033 N034 N035 N036 N037 N038 N039 N040 N041 N042 N043 N044 N045 N046 N047 N048 N049 Description RECURRENT AND PERSISTENT HEMATURIA WITH UNSPECIFIED MORPHOLOGIC CHANGES CHRONIC NEPHRITIC SYNDROME WITH MINOR GLOMERULAR ABNORMALITY CHRONIC NEPHRITIC SYNDROME WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH DENSE DEPOSIT DISEASE CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS CHRONIC NEPHRITIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES CHRONIC NEPHRITIC SYNDROME WITH UNSPECIFIED MORPHOLOGIC CHANGES NEPHROTIC SYNDROME WITH MINOR GLOMERULAR ABNORMALITY NEPHROTIC SYNDROME WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS NEPHROTIC SYNDROME WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH DENSE DEPOSIT DISEASE NEPHROTIC SYNDROME WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS NEPHROTIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES NEPHROTIC SYNDROME WITH UNSPECIFIED MORPHOLOGIC CHANGES 06/18/2018 9

10 Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years ICD-10 Code N050 N051 N052 N053 N054 N055 N056 N057 N058 N059 N060 N061 N062 N063 N064 N065 N066 N067 N068 N069 N070 Description UNSPECIFIED NEPHRITIC SYNDROME WITH MINOR GLOMERULAR ABNORMALITY UNSPECIFIED NEPHRITIC SYNDROME WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH DENSE DEPOSIT DISEASE UNSPECIFIED NEPHRITIC SYNDROME WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS UNSPECIFIED NEPHRITIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES UNSPECIFIED NEPHRITIC SYNDROME WITH UNSPECIFIED MORPHOLOGIC CHANGES ISOLATED PROTEINURIA WITH MINOR GLOMERULAR ABNORMALITY ISOLATED PROTEINURIA WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS ISOLATED PROTEINURIA WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH DENSE DEPOSIT DISEASE ISOLATED PROTEINURIA WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS ISOLATED PROTEINURIA WITH OTHER MORPHOLOGIC LESION ISOLATED PROTEINURIA WITH UNSPECIFIED MORPHOLOGIC LESION HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH MINOR GLOMERULAR ABNORMALITY 06/18/

11 ICD-10 Code N071 N072 N073 N074 N075 N076 N077 N078 N079 N08 N140 N141 N142 N143 N144 N150 N158 N159 N16 N171 N172 Description Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE MEMBRANOUS GLOMERULONEPHRITIS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE MESANGIAL PROLIFERATIVE GLOMERULONEPHRITIS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE GLOMERULONEPHRITIS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE MESANGIOCAPILLARY GLOMERULONEPHRITIS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DENSE DEPOSIT DISEASE HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH DIFFUSE CRESCENTIC GLOMERULONEPHRITIS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH OTHER MORPHOLOGIC LESIONS HEREDITARY NEPHROPATHY, NOT ELSEWHERE CLASSIFIED WITH UNSPECIFIED MORPHOLOGIC LESIONS GLOMERULAR DISORDERS IN DISEASES CLASSIFIED ELSEWHERE ANALGESIC NEPHROPATHY NEPHROPATHY INDUCED BY OTHER DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES NEPHROPATHY INDUCED BY UNSPECIFIED DRUG, MEDICAMENT OR BIOLOGICAL SUBSTANCE NEPHROPATHY INDUCED BY HEAVY METALS TOXIC NEPHROPATHY, NOT ELSEWHERE CLASSIFIED BALKAN NEPHROPATHY OTHER SPECIFIED RENAL TUBULO-INTERSTITIAL DISEASES RENAL TUBULO-INTERSTITIAL DISEASE, UNSPECIFIED RENAL TUBULO-INTERSTITIAL DISORDERS IN DISEASES CLASSIFIED ELSEWHERE ACUTE KIDNEY FAILURE WITH ACUTE CORTICAL NECROSIS ACUTE KIDNEY FAILURE WITH MEDULLARY NECROSIS N181 CHRONIC KIDNEY DISEASE, STAGE 1 N182 N183 N184 CHRONIC KIDNEY DISEASE, STAGE 2 (MILD) CHRONIC KIDNEY DISEASE, STAGE 3 (MODERATE) CHRONIC KIDNEY DISEASE, STAGE 4 (SEVERE) 06/18/

12 Step 4 (diagnosis of CKD) Required diagnosis: 1 Look back timeframe: 3 years ICD-10 Code Description N185 CHRONIC KIDNEY DISEASE, STAGE 5 N186 N189 N19 N250 N251 N259 N261 N269 END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED UNSPECIFIED KIDNEY FAILURE RENAL OSTEODYSTROPHY NEPHROGENIC DIABETES INSIPIDUS DISORDER RESULTING FROM IMPAIRED RENAL TUBULAR FUNCTION, UNSPECIFIED ATROPHY OF KIDNEY (TERMINAL) RENAL SCLEROSIS, UNSPECIFIED Step 5 (history of renal transplant procedural code) Required procedure: 1 Look back timeframe: 3 years CPT Code Description REMOVAL OF DONOR KIDNEY REMOVE CADAVER DONOR KIDNEY REMOVE KIDNEY, LIVING DONOR REMOVAL OF KIDNEY TRANSPLANTATION OF KIDNEY TRANSPLANTATION OF KIDNEY REMOVE TRANSPLANTED KIDNEY REIMPLANTATION OF KIDNEY 06/18/

13 Step 6 Testing Requirements Deficiency, Idiopathic Short Stature, Small For Gestational Age, Panhypopituitarism, Chronic Kidney Disease, SHOX deficiency, Turner Syndrome, Noonan Syndrome and Prader-Willi Syndrome in Children Diagnosis Testing Requirements: For initial requests, documentation must be from within the past 12 months. For renewal requests, documentation must be from within the past 6 months Panhypopituitarism Initiation of GH Therapy: IGF-1 level < 160 ng/ml, AND Failure to respond (response 5 ng/ml) to one growth hormone stimulation test (Note: children < 12 months of age are excluded from provocative testing) Renewal of GH Therapy: No additional testing is required Deficiency Initiation of GH Therapy: Failure to respond (response < 10 ng/ml) to at least 2 growth hormone stimulation tests (Note: children < 12 months of age are excluded from provocative testing), AND Patient s height > 2.25 SD below the mean for age OR patient s height > 2 SD below the midparental height percentile, AND Growth velocity < 25th percentile for bone age Renewal of GH Therapy: Patient s growth should exceed 2 cm/year, AND Epiphyses are open Idiopathic Short Stature Initiation of GH Therapy: Height > 2.25 SD below the mean for age, AND Predicted adult height < 63 inches for males and < 59 inches for females Renewal of GH Therapy: Patient s growth should exceed 2 cm/year, OR show an increase in height velocity of 50%, OR an increase of at least 2.5 cm/year above the baseline height velocity, AND Epiphyses are open 06/18/

14 Step 6 Testing Requirements Deficiency, Idiopathic Short Stature, Small For Gestational Age, Panhypopituitarism, Chronic Kidney Disease, SHOX deficiency, Turner Syndrome, Noonan Syndrome and Prader-Willi Syndrome in Children Diagnosis Testing Requirements: For initial requests, documentation must be from within the past 12 months. For renewal requests, documentation must be from within the past 6 months Small for Gestational Age (SGA) Initiation of GH Therapy: Birth length or birth weight below 5th percentile, AND If age less than 3 years, height is below the 10th percentile on growth chart OR if age 3 years or older, epiphyses are open Renewal of GH Therapy: Epiphyses are open, AND Growth exceeds 2 cm/year Chronic Kidney Disease Initiation of GH Therapy: GFR 75mL/min/1.73m 2, AND Patient s height > 2.25 SD below the mean for age OR patient s height > 2 SD below the midparental height percentile OR patient s Z score < -1.88, AND Pre-transplant Renewal of GH Therapy: Patient s growth should exceed 2 cm/year, AND Pre-transplant, AND Epiphyses are open SHOX deficiency, Turner Syndrome, Noonan Syndrome and Prader-Willi Syndrome Diagnosis only is required, no additional testing is requested 06/18/

15 Step 7 (diagnosis of panhypopituitarism) Required diagnosis: 1 Look back timeframe: 3 years ICD-9 Code Description 2532 PANHYPOPITUITARISM 2533 PITUITARY DWARFISM 2537 IATROGENIC PITUITARY DISORDERS ICD-10 Code Description E230 HYPOPITUITARISM E893 POSTPROCEDURAL HYPOPITUITARISM Step 8 (diagnosis of GHD or ISS) Required diagnosis: 1 Look back timeframe: 3 years ICD-9 Code Description 2533 PITUITARY DWARFISM FET GROWTH RETARD WT NOS FET GROWTH RETARD <500G FET GROWTH RET G FET GROWTH RET G FET GRWTH RET G FET GRWTH RET G FET GRWTH RET G FET GRWTH RET G FET GRWTH RET G FET GROWTH RET 2500+G SHORT STATURE ICD-10 Code Description E343 SHORT STATURE DUE TO ENDOCRINE DISORDER P059 NEWBORN AFFECTED BY SLOW INTRAUTERINE GROWTH, UNSPECIFIED R6252 SHORT STATURE (CHILD) 06/18/

16 Step 10 Testing Requirements Panhypopituitarism, Deficiency or Idiopathic Short Stature in patients > 16 years of age Diagnosis Testing Requirements: For initial requests, documentation must be from within the past 12 months. For renewal requests, documentation must be from within the past 6 months Panhypopituitarism Initiation of GH Therapy: IGF-1 level < 160 ng/ml, AND Failure to respond to one growth hormone stimulation test (response 5ng/mL) Renewal of GH Therapy: No additional testing is required Deficiency (GHD)/ Idiopathic Short Stature (ISS) Renewal of GH Therapy: If patient has been treated as a pediatric patient ( 16 years of age) and is requesting a refill, patient s growth should exceed 2 cm/year, AND Bone age < 16 years, AND Epiphyses are open ICD-9 Code Description 1400 MAL NEO UPPER VERMILION 1401 MAL NEO LOWER VERMILION 1403 MAL NEO UPPER LIP, INNER 1404 MAL NEO LOWER LIP, INNER 1405 MAL NEO LIP, INNER NOS 1406 MAL NEO LIP, COMMISSURE 1408 MAL NEO LIP NEC 1409 MAL NEO LIP/VERMIL NOS 1410 MAL NEO TONGUE BASE 1411 MAL NEO DORSAL TONGUE 1412 MAL NEO TIP/LAT TONGUE 06/18/

17 ICD-9 Code Description 1413 MAL NEO VENTRAL TONGUE 1414 MAL NEO ANT 2/3 TONGUE 1415 MAL NEO TONGUE JUNCTION 1416 MAL NEO LINGUAL TONSIL 1418 MALIG NEO TONGUE NEC 1419 MALIG NEO TONGUE NOS 1420 MALIG NEO PAROTID 1421 MALIG NEO SUBMANDIBULAR 1422 MALIG NEO SUBLINGUAL 1428 MAL NEO MAJ SALIVARY NEC 1429 MAL NEO SALIVARY NOS 1430 MALIG NEO UPPER GUM 1431 MALIG NEO LOWER GUM 1438 MALIG NEO GUM NEC 1439 MALIG NEO GUM NOS 1440 MAL NEO ANT FLOOR MOUTH 1441 MAL NEO LAT FLOOR MOUTH 1448 MAL NEO MOUTH FLOOR NEC 1449 MAL NEO MOUTH FLOOR NOS 1450 MAL NEO CHEEK MUCOSA 1451 MAL NEO MOUTH VESTIBULE 1452 MALIG NEO HARD PALATE 1453 MALIG NEO SOFT PALATE 1454 MALIGNANT NEOPLASM UVULA 1455 MALIGNANT NEO PALATE NOS 1456 MALIG NEO RETROMOLAR 1458 MALIG NEOPLASM MOUTH NEC 1459 MALIG NEOPLASM MOUTH NOS 1460 MALIGNANT NEOPL TONSIL 1461 MAL NEO TONSILLAR FOSSA 1462 MAL NEO TONSIL PILLARS 1463 MALIGN NEOPL VALLECULA 1464 MAL NEO ANT EPIGLOTTIS 1465 MAL NEO EPIGLOTTIS JUNCT 1466 MAL NEO LAT OROPHARYNX 06/18/

18 ICD-9 Code Description 1467 MAL NEO POST OROPHARYNX 1468 MAL NEO OROPHARYNX NEC 1469 MALIG NEO OROPHARYNX NOS 1470 MAL NEO SUPER NASOPHARYN 1471 MAL NEO POST NASOPHARYNX 1472 MAL NEO LAT NASOPHARYNX 1473 MAL NEO ANT NASOPHARYNX 1478 MAL NEO NASOPHARYNX NEC 1479 MAL NEO NASOPHARYNX NOS 1480 MAL NEO POSTCRICOID 1481 MAL NEO PYRIFORM SINUS 1482 MAL NEO ARYEPIGLOTT FOLD 1483 MAL NEO POST HYPOPHARYNX 1488 MAL NEO HYPOPHARYNX NEC 1489 MAL NEO HYPOPHARYNX NOS 1490 MAL NEO PHARYNX NOS 1491 MAL NEO WALDEYER'S RING 1498 MAL NEO ORAL/PHARYNX NEC 1499 MAL NEO OROPHRYN ILL-DEF 1500 MAL NEO CERVICAL ESOPHAG 1501 MAL NEO THORACIC ESOPHAG 1502 MAL NEO ABDOMIN ESOPHAG 1503 MAL NEO UPPER 3RD ESOPH 1504 MAL NEO MIDDLE 3RD ESOPH 1505 MAL NEO LOWER 3RD ESOPH 1508 MAL NEO ESOPHAGUS NEC 1509 MAL NEO ESOPHAGUS NOS 1510 MAL NEO STOMACH CARDIA 1511 MALIGNANT NEO PYLORUS 1512 MAL NEO PYLORIC ANTRUM 1513 MAL NEO STOMACH FUNDUS 1514 MAL NEO STOMACH BODY 1515 MAL NEO STOM LESSER CURV 1516 MAL NEO STOM GREAT CURV 1518 MALIG NEOPL STOMACH NEC 06/18/

19 1519 MALIG NEOPL STOMACH NOS 1520 MALIGNANT NEOPL DUODENUM 1521 MALIGNANT NEOPL JEJUNUM 1522 MALIGNANT NEOPLASM ILEUM 1523 MAL NEO MECKEL'S DIVERT 1528 MAL NEO SMALL BOWEL NEC 1529 MAL NEO SMALL BOWEL NOS 1530 MAL NEO HEPATIC FLEXURE 1531 MAL NEO TRANSVERSE COLON 1532 MAL NEO DESCEND COLON 1533 MAL NEO SIGMOID COLON 1534 MALIGNANT NEOPLASM CECUM 1535 MALIGNANT NEO APPENDIX 1536 MALIG NEO ASCEND COLON 1537 MAL NEO SPLENIC FLEXURE 1538 MALIGNANT NEO COLON NEC 1539 MALIGNANT NEO COLON NOS 1540 MAL NEO RECTOSIGMOID JCT 1541 MALIGNANT NEOPL RECTUM 1542 MALIG NEOPL ANAL CANAL 1543 MALIGNANT NEO ANUS NOS 1548 MAL NEO RECTUM/ANUS NEC 1550 MAL NEO LIVER, PRIMARY 1551 MAL NEO INTRAHEPAT DUCTS 1552 MALIGNANT NEO LIVER NOS 1560 MALIG NEO GALLBLADDER 1561 MAL NEO EXTRAHEPAT DUCTS 1562 MAL NEO AMPULLA OF VATER 1568 MALIG NEO BILIARY NEC 1569 MALIG NEO BILIARY NOS 1570 MAL NEO PANCREAS HEAD 1571 MAL NEO PANCREAS BODY 1572 MAL NEO PANCREAS TAIL 1573 MAL NEO PANCREATIC DUCT 1574 MAL NEO ISLET LANGERHANS 1578 MALIG NEO PANCREAS NEC 06/18/

20 1579 MALIG NEO PANCREAS NOS 1580 MAL NEO RETROPERITONEUM 1588 MAL NEO PERITONEUM NEC 1589 MAL NEO PERITONEUM NOS 1590 MALIG NEO INTESTINE NOS 1591 MALIGNANT NEO SPLEEN NEC 1598 MAL NEO GI/INTRA-ABD NEC 1599 MAL NEO GI TRACT ILL-DEF 1600 MAL NEO NASAL CAVITIES 1601 MALIG NEO MIDDLE EAR 1602 MAL NEO MAXILLARY SINUS 1603 MAL NEO ETHMOIDAL SINUS 1604 MALIG NEO FRONTAL SINUS 1605 MAL NEO SPHENOID SINUS 1608 MAL NEO ACCESS SINUS NEC 1609 MAL NEO ACCESS SINUS NOS 1610 MALIGNANT NEO GLOTTIS 1611 MALIG NEO SUPRAGLOTTIS 1612 MALIG NEO SUBGLOTTIS 1613 MAL NEO CARTILAGE LARYNX 1618 MALIGNANT NEO LARYNX NEC 1619 MALIGNANT NEO LARYNX NOS 1620 MALIGNANT NEO TRACHEA 1622 MALIG NEO MAIN BRONCHUS 1623 MAL NEO UPPER LOBE LUNG 1624 MAL NEO MIDDLE LOBE LUNG 1625 MAL NEO LOWER LOBE LUNG 1628 MAL NEO BRONCH/LUNG NEC 1629 MAL NEO BRONCH/LUNG NOS 1630 MAL NEO PARIETAL PLEURA 1631 MAL NEO VISCERAL PLEURA 1638 MALIG NEOPL PLEURA NEC 1639 MALIG NEOPL PLEURA NOS 1640 MALIGNANT NEOPL THYMUS 1641 MALIGNANT NEOPL HEART 1642 MAL NEO ANT MEDIASTINUM 06/18/

21 1643 MAL NEO POST MEDIASTINUM 1648 MAL NEO MEDIASTINUM NEC 1649 MAL NEO MEDIASTINUM NOS 1650 MAL NEO UPPER RESP NOS 1658 MAL NEO THORAX/RESP NEC 1659 MAL NEO RESP SYSTEM NOS 1700 MAL NEO SKULL/FACE BONE 1701 MALIGNANT NEO MANDIBLE 1702 MALIG NEO VERTEBRAE 1703 MAL NEO RIBS/STERN/CLAV 1704 MAL NEO LONG BONES ARM 1705 MAL NEO BONES WRIST/HAND 1706 MAL NEO PELVIC GIRDLE 1707 MAL NEO LONG BONES LEG 1708 MAL NEO BONES ANKLE/FOOT 1709 MALIG NEOPL BONE NOS 1710 MAL NEO SOFT TISSUE HEAD 1712 MAL NEO SOFT TISSUE ARM 1713 MAL NEO SOFT TISSUE LEG 1714 MAL NEO SOFT TIS THORAX 1715 MAL NEO SOFT TIS ABDOMEN 1716 MAL NEO SOFT TIS PELVIS 1717 MAL NEOPL TRUNK NOS 1718 MAL NEO SOFT TISSUE NEC 1719 MAL NEO SOFT TISSUE NOS 1720 MALIG MELANOMA LIP 1721 MALIG MELANOMA EYELID 1722 MALIG MELANOMA EAR 1723 MAL MELANOM FACE NEC/NOS 1724 MAL MELANOMA SCALP/NECK 1725 MALIG MELANOMA TRUNK 1726 MALIG MELANOMA ARM 1727 MALIG MELANOMA LEG 1728 MALIG MELANOMA SKIN NEC 1729 MALIG MELANOMA SKIN NOS 1730 MALIG NEO SKIN LIP 06/18/

22 1731 MALIG NEO SKIN EYELID 1732 MALIG NEO SKIN EAR 1733 MAL NEO SKIN FACE NEC 1734 MAL NEO SCALP/SKIN NECK 1735 MALIG NEO SKIN TRUNK 1736 MALIG NEO SKIN ARM 1737 MALIG NEO SKIN LEG 1738 MALIG NEO SKIN NEC 1739 MALIG NEO SKIN NOS 1740 MALIG NEO NIPPLE 1741 MAL NEO BREAST-CENTRAL 1742 MAL NEO BREAST UP-INNER 1743 MAL NEO BREAST LOW-INNER 1744 MAL NEO BREAST UP-OUTER 1745 MAL NEO BREAST LOW-OUTER 1746 MAL NEO BREAST-AXILLARY 1748 MALIGN NEOPL BREAST NEC 1749 MALIGN NEOPL BREAST NOS 1750 MAL NEO MALE NIPPLE 1759 MAL NEO MALE BREAST NEC 1760 SKIN - KAPOSI'S SARCOMA 1761 SFT TISUE - KPSI'S SRCMA 1762 PALATE - KPSI's SARCOMA 1763 GI SITES - KPSI'S SRCOMA 1764 LUNG - KAPOSI'S SARCOMA 1765 LYM NDS - KPSI'S SARCOMA 1768 SPF STS - KPSI'S SARCOMA 1769 KAPOSI'S SARCOMA NOS 179 MALIG NEOPL UTERUS NOS 1800 MALIG NEO ENDOCERVIX 1801 MALIG NEO EXOCERVIX 1808 MALIG NEO CERVIX NEC 1809 MAL NEO CERVIX UTERI NOS 181 MALIGNANT NEOPL PLACENTA 1820 MALIG NEO CORPUS UTERI 1821 MAL NEO UTERINE ISTHMUS 06/18/

23 1828 MAL NEO BODY UTERUS NEC 1830 MALIGN NEOPL OVARY 1832 MAL NEO FALLOPIAN TUBE 1833 MAL NEO BROAD LIGAMENT 1834 MALIG NEO PARAMETRIUM 1835 MAL NEO ROUND LIGAMENT 1838 MAL NEO ADNEXA NEC 1839 MAL NEO ADNEXA NOS 1840 MALIGN NEOPL VAGINA 1841 MAL NEO LABIA MAJORA 1842 MAL NEO LABIA MINORA 1843 MALIGN NEOPL CLITORIS 1844 MALIGN NEOPL VULVA NOS 1848 MAL NEO FEMALE GENIT NEC 1849 MAL NEO FEMALE GENIT NOS 185 MALIGN NEOPL PROSTATE 1860 MAL NEO UNDESCEND TESTIS 1869 MALIG NEO TESTIS NEC 1871 MALIGN NEOPL PREPUCE 1872 MALIG NEO GLANS PENIS 1873 MALIG NEO PENIS BODY 1874 MALIG NEO PENIS NOS 1875 MALIG NEO EPIDIDYMIS 1876 MAL NEO SPERMATIC CORD 1877 MALIGN NEOPL SCROTUM 1878 MAL NEO MALE GENITAL NEC 1879 MAL NEO MALE GENITAL NOS 1880 MAL NEO BLADDER-TRIGONE 1881 MAL NEO BLADDER-DOME 1882 MAL NEO BLADDER-LATERAL 1883 MAL NEO BLADDER-ANTERIOR 1884 MAL NEO BLADDER-POST 1885 MAL NEO BLADDER NECK 1886 MAL NEO URETERIC ORIFICE 1887 MALIG NEO URACHUS 1888 MALIG NEO BLADDER NEC 06/18/

24 1889 MALIG NEO BLADDER NOS 1890 MALIG NEOPL KIDNEY 1891 MALIG NEO RENAL PELVIS 1892 MALIGN NEOPL URETER 1893 MALIGN NEOPL URETHRA 1894 MAL NEO PARAURETHRAL 1898 MAL NEO URINARY NEC 1899 MAL NEO URINARY NOS 1900 MALIGN NEOPL EYEBALL 1901 MALIGN NEOPL ORBIT 1902 MAL NEO LACRIMAL GLAND 1903 MAL NEO CONJUNCTIVA 1904 MALIGN NEOPL CORNEA 1905 MALIGN NEOPL RETINA 1906 MALIGN NEOPL CHOROID 1907 MAL NEO LACRIMAL DUCT 1908 MALIGN NEOPL EYE NEC 1909 MALIGN NEOPL EYE NOS 1910 MALIGN NEOPL CEREBRUM 1911 MALIG NEO FRONTAL LOBE 1912 MAL NEO TEMPORAL LOBE 1913 MAL NEO PARIETAL LOBE 1914 MAL NEO OCCIPITAL LOBE 1915 MAL NEO CEREB VENTRICLE 1916 MAL NEO CEREBELLUM NOS 1917 MAL NEO BRAIN STEM 1918 MALIG NEO BRAIN NEC 1919 MALIG NEO BRAIN NOS 1920 MAL NEO CRANIAL NERVES 1921 MAL NEO CEREBRAL MENING 1922 MAL NEO SPINAL CORD 1923 MAL NEO SPINAL MENINGES 1928 MAL NEO NERVOUS SYST NEC 1929 MAL NEO NERVOUS SYST NOS 193 MALIGN NEOPL THYROID 1940 MALIGN NEOPL ADRENAL 06/18/

25 1941 MALIG NEO PARATHYROID 1943 MALIG NEO PITUITARY 1944 MALIGN NEO PINEAL GLAND 1945 MAL NEO CAROTID BODY 1946 MAL NEO PARAGANGLIA NEC 1948 MAL NEO ENDOCRINE NEC 1949 MAL NEO ENDOCRINE NOS 1950 MAL NEO HEAD/FACE/NECK 1951 MALIGN NEOPL THORAX 1952 MALIG NEO ABDOMEN 1953 MALIGN NEOPL PELVIS 1954 MALIGN NEOPL ARM 1955 MALIGN NEOPL LEG 1958 MALIG NEO SITE NEC 1960 MAL NEO LYMPH-HEAD/NECK 1961 MAL NEO LYMPH-INTRATHOR 1962 MAL NEO LYMPH INTRA-ABD 1963 MAL NEO LYMPH-AXILLA/ARM 1965 MAL NEO LYMPH-INGUIN/LEG 1966 MAL NEO LYMPH-INTRAPELV 1968 MAL NEO LYMPH NODE-MULT 1969 MAL NEO LYMPH NODE NOS 1970 SECONDARY MALIG NEO LUNG 1971 SEC MAL NEO MEDIASTINUM 1972 SECOND MALIG NEO PLEURA 1973 SEC MALIG NEO RESP NEC 1974 SEC MALIG NEO SM BOWEL 1975 SEC MALIG NEO LG BOWEL 1976 SEC MAL NEO PERITONEUM 1977 SECOND MALIG NEO LIVER 1978 SEC MAL NEO GI NEC 1980 SECOND MALIG NEO KIDNEY 1981 SEC MALIG NEO URIN NEC 1982 SECONDARY MALIG NEO SKIN 1983 SEC MAL NEO BRAIN/SPINE 1984 SEC MALIG NEO NERVE NEC 06/18/

26 1985 SECONDARY MALIG NEO BONE 1986 SECOND MALIG NEO OVARY 1987 SECOND MALIG NEO ADRENAL SECOND MALIG NEO BREAST SECOND MALIG NEO GENITAL SECONDARY MALIG NEO NEC 1990 MALIG NEO DISSEMINATED 1991 MALIGNANT NEOPLASM NOS 1992 MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN RETCLSRC UNSP XTRNDL ORG RETICULOSARCOMA HEAD RETICULOSARCOMA THORAX RETICULOSARCOMA ABDOM RETICULOSARCOMA AXILLA RETICULOSARCOMA INGUIN RETICULOSARCOMA PELVIC RETICULOSARCOMA SPLEEN RETICULOSARCOMA MULT LYMPHSRC UNSP XTRNDL ORG LYMPHOSARCOMA HEAD LYMPHOSARCOMA THORAX LYMPHOSARCOMA ABDOM LYMPHOSARCOMA AXILLA LYMPHOSARCOMA INGUIN LYMPHOSARCOMA PELVIC LYMPHOSARCOMA SPLEEN LYMPHOSARCOMA MULT BRKT TMR UNSP XTRNDL ORG BURKITT'S TUMOR HEAD BURKITT'S TUMOR THORAX BURKITT'S TUMOR ABDOM BURKITT'S TUMOR AXILLA BURKITT'S TUMOR INGUIN BURKITT'S TUMOR PELVIC BURKITT'S TUMOR SPLEEN BURKITT'S TUMOR MULT 06/18/

27 20030 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 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 06/18/

28 20057 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 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 OTH VARN UNSP XTRNDL ORG MIXED LYMPHOSARC HEAD MIXED LYMPHOSARC THORAX MIXED LYMPHOSARC ABDOM MIXED LYMPHOSARC AXILLA MIXED LYMPHOSARC INGUIN MIXED LYMPHOSARC PELVIC MIXED LYMPHOSARC SPLEEN 06/18/

29 20088 MIXED LYMPHOSARC MULT HDGK PRG UNSP XTRNDL ORG HODGKINS PARAGRAN HEAD HODGKINS PARAGRAN THORAX HODGKINS PARAGRAN ABDOM HODGKINS PARAGRAN AXILLA HODGKINS PARAGRAN INGUIN HODGKINS PARAGRAN PELVIC HODGKINS PARAGRAN SPLEEN HODGKINS PARAGRAN MULT HDGK GRN UNSP XTRNDL ORG HODGKINS GRANULOM HEAD HODGKINS GRANULOM THORAX HODGKINS GRANULOM ABDOM HODGKINS GRANULOM AXILLA HODGKINS GRANULOM INGUIN HODGKINS GRANULOM PELVIC HODGKINS GRANULOM SPLEEN HODGKINS GRANULOM MULT HDGK SRC UNSP XTRNDL ORG HODGKINS SARCOMA HEAD HODGKINS SARCOMA THORAX HODGKINS SARCOMA ABDOM HODGKINS SARCOMA AXILLA HODGKINS SARCOMA INGUIN HODGKINS SARCOMA PELVIC HODGKINS SARCOMA SPLEEN HODGKINS SARCOMA MULT LYM-HST UNSP XTRNDL ORGN HODG LYMPH-HISTIO HEAD HODG LYMPH-HISTIO THORAX HODG LYMPH-HISTIO ABDOM HODG LYMPH-HISTIO AXILLA HODG LYMPH-HISTIO INGUIN HODG LYMPH-HISTIO PELVIC HODG LYMPH-HISTIO SPLEEN 06/18/

30 20148 HODG LYMPH-HISTIO MULT NDR SCLR UNSP XTRNDL ORG HODG NODUL SCLERO HEAD HODG NODUL SCLERO THORAX HODG NODUL SCLERO ABDOM HODG NODUL SCLERO AXILLA HODG NODUL SCLERO INGUIN HODG NODUL SCLERO PELVIC HODG NODUL SCLERO SPLEEN HODG NODUL SCLERO MULT MXD CELR UNSP XTRNDL ORG HODGKINS MIX CELL HEAD HODGKINS MIX CELL THORAX HODGKINS MIX CELL ABDOM HODGKINS MIX CELL AXILLA HODGKINS MIX CELL INGUIN HODGKINS MIX CELL PELVIC HODGKINS MIX CELL SPLEEN HODGKINS MIX CELL MULT LYM DPLT UNSP XTRNDL ORG HODG LYMPH DEPLET HEAD HODG LYMPH DEPLET THORAX HODG LYMPH DEPLET ABDOM HODG LYMPH DEPLET AXILLA HODG LYMPH DEPLET INGUIN HODG LYMPH DEPLET PELVIC HODG LYMPH DEPLET SPLEEN HODG LYMPH DEPLET MULT HDGK DIS UNSP XTRNDL ORG HODGKINS DIS NOS HEAD HODGKINS DIS NOS THORAX HODGKINS DIS NOS ABDOM HODGKINS DIS NOS AXILLA HODGKINS DIS NOS INGUIN HODGKINS DIS NOS PELVIC HODGKINS DIS NOS SPLEEN 06/18/

31 20198 HODGKINS DIS NOS MULT NDLR LYM UNSP XTRNDL ORG NODULAR LYMPHOMA HEAD NODULAR LYMPHOMA THORAX NODULAR LYMPHOMA ABDOM NODULAR LYMPHOMA AXILLA NODULAR LYMPHOMA INGUIN NODULAR LYMPHOMA PELVIC NODULAR LYMPHOMA SPLEEN NODULAR LYMPHOMA MULT MYCS FNG UNSP XTRNDL ORG MYCOSIS FUNGOIDES HEAD MYCOSIS FUNGOIDES THORAX MYCOSIS FUNGOIDES ABDOM MYCOSIS FUNGOIDES AXILLA MYCOSIS FUNGOIDES INGUIN MYCOSIS FUNGOIDES PELVIC MYCOSIS FUNGOIDES SPLEEN MYCOSIS FUNGOIDES MULT SZRY DIS UNSP XTRNDL ORG SEZARY'S DISEASE HEAD SEZARY'S DISEASE THORAX SEZARY'S DISEASE ABDOM SEZARY'S DISEASE AXILLA SEZARY'S DISEASE INGUIN SEZARY'S DISEASE PELVIC SEZARY'S DISEASE SPLEEN SEZARY'S DISEASE MULT MLG HIST UNSP XTRNDL ORG MAL HISTIOCYTOSIS HEAD MAL HISTIOCYTOSIS THORAX MAL HISTIOCYTOSIS ABDOM MAL HISTIOCYTOSIS AXILLA MAL HISTIOCYTOSIS INGUIN MAL HISTIOCYTOSIS PELVIC MAL HISTIOCYTOSIS SPLEEN 06/18/

32 20238 MAL HISTIOCYTOSIS MULT LK RTCTL UNSP XTRNDL ORG HAIRY-CELL LEUKEM HEAD HAIRY-CELL LEUKEM THORAX HAIRY-CELL LEUKEM ABDOM HAIRY-CELL LEUKEM AXILLA HAIRY-CELL LEUKEM INGUIN HAIRY-CELL LEUKEM PELVIC HAIRY-CELL LEUKEM SPLEEN HAIRY-CELL LEUKEM MULT LTR-SIWE UNSP XTRNDL ORG LETTERER-SIWE DIS HEAD LETTERER-SIWE DIS THORAX LETTERER-SIWE DIS ABDOM LETTERER-SIWE DIS AXILLA LETTERER-SIWE DIS INGUIN LETTERER-SIWE DIS PELVIC LETTERER-SIWE DIS SPLEEN LETTERER-SIWE DIS MULT MLG MAST UNSP XTRNDL ORG MAL MASTOCYTOSIS HEAD MAL MASTOCYTOSIS THORAX MAL MASTOCYTOSIS ABDOM MAL MASTOCYTOSIS AXILLA MAL MASTOCYTOSIS INGUIN MAL MASTOCYTOSIS PELVIC MAL MASTOCYTOSIS SPLEEN MAL MASTOCYTOSIS MULT 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 06/18/

33 20275 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 OTH LYMP UNSP XTRNDL ORG LYMPHOMAS NEC HEAD LYMPHOMAS NEC THORAX LYMPHOMAS NEC ABDOM LYMPHOMAS NEC AXILLA LYMPHOMAS NEC INGUIN LYMPHOMAS NEC PELVIC LYMPHOMAS NEC SPLEEN LYMPHOMAS NEC MULT UNSP LYM UNSP XTRNDL ORG LYMPHOID MAL NEC HEAD LYMPHOID MAL NEC THORAX LYMPHOID MAL NEC ABDOM LYMPHOID MAL NEC AXILLA LYMPHOID MAL NEC INGUIN LYMPHOID MAL NEC PELVIC LYMPHOID MAL NEC SPLEEN LYMPHOID MAL NEC MULT MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MULT MYELM W REMISSION MULTIPLE MYELOMA, IN RELAPSE PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION PLSM CELL LEUK W RMSON PLASMA CELL LEUKEMIA, IN RELAPSE OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTH IMNPRFL NPL W RMSN OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 06/18/

34 20401 ACT LYM LEUK W RMSION ACUTE LYMPHOID LEUKEMIA, IN RELAPSE CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHR LYM LEUK W RMSION CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION SBAC LYM LEUK W RMSION SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTH LYM LEUK W RMSION OTHER LYMPHOID LEUKEMIA, IN RELAPSE UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION UNS LYM LEUK W RMSION UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION ACT MYL LEUK W RMSION ACUTE MYELOID LEUKEMIA, IN RELAPSE CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHR MYL LEUK W RMSION CHRONIC MYELOID LEUKEMIA, IN RELAPSE SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION SBAC MYL LEUK W RMSION SUBACUTE MYELOID LEUKEMIA, IN RELAPSE MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MYL SRCOMA W RMSION MYELOID SARCOMA, IN RELAPSE OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTH MYL LEUK W RMSION OTHER MYELOID LEUKEMIA, IN RELAPSE 06/18/

35 20590 UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION UNS MYL LEUK W RMSION UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION ACT MONO LEUK W RMSION ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHR MONO LEUK W RMSION CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION SBAC MONO LEUK W RMSION SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTH MONO LEUK W RMSION OTHER MONOCYTIC LEUKEMIA, IN RELAPSE UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION UNS MONO LEUK W RMSION UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION ACT ERTH/ERYLK W RMSON ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHR ERYTHRM W REMISION CHRONIC ERYTHREMIA, IN RELAPSE MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MGKRYCYT LEUK W RMSION MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 06/18/

36 20781 OTH SPF LEUK W REMSION OTHER SPECIFIED LEUKEMIA, IN RELAPSE ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION ACT LEUK UNS CL W RMSON ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHR LEUK UNS CL W RMSON CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION SBAC LEUK UNS CL W RMSON SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION OTH LEUK UNS CL W RMSON OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION LEUKEMIA NOS W REMISSION ICD-10 Code C000 C001 C002 C003 C004 C005 C006 C008 C009 C01 C020 C021 C022 C023 Description MALIGNANT NEOPLASM OF EXTERNAL UPPER LIP MALIGNANT NEOPLASM OF EXTERNAL LOWER LIP MALIGNANT NEOPLASM OF EXTERNAL LIP, UNSPECIFIED 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, UNSPECIFIED MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LIP MALIGNANT NEOPLASM OF LIP, UNSPECIFIED MALIGNANT NEOPLASM OF BASE OF TONGUE MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUE MALIGNANT NEOPLASM OF BORDER OF TONGUE MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE, PART UNSPECIFIED 06/18/

37 C024 C028 C029 C030 C031 C039 C040 C041 C048 C049 C050 C051 C052 C058 C059 C060 C061 C062 C0680 C0689 C069 C07 C080 C081 C089 C090 C091 C098 C099 C100 C101 C102 C103 MALIGNANT NEOPLASM OF LINGUAL TONSIL MALIGNANT NEOPLASM OF OVERLAPPING SITES OF TONGUE MALIGNANT NEOPLASM OF TONGUE, UNSPECIFIED MALIGNANT NEOPLASM OF UPPER GUM MALIGNANT NEOPLASM OF LOWER GUM MALIGNANT NEOPLASM OF GUM, UNSPECIFIED MALIGNANT NEOPLASM OF ANTERIOR FLOOR OF MOUTH MALIGNANT NEOPLASM OF LATERAL FLOOR OF MOUTH MALIGNANT NEOPLASM OF OVERLAPPING SITES OF FLOOR OF MOUTH MALIGNANT NEOPLASM OF FLOOR OF MOUTH, UNSPECIFIED MALIGNANT NEOPLASM OF HARD PALATE MALIGNANT NEOPLASM OF SOFT PALATE MALIGNANT NEOPLASM OF UVULA MALIGNANT NEOPLASM OF OVERLAPPING SITES OF PALATE MALIGNANT NEOPLASM OF PALATE, UNSPECIFIED MALIGNANT NEOPLASM OF CHEEK MUCOSA MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH MALIGNANT NEOPLASM OF RETROMOLAR AREA MALIGNANT NEOPLASM OF OVERLAPPING SITES OF UNSPECIFIED PARTS OF MOUTH MALIGNANT NEOPLASM OF OVERLAPPING SITES OF OTHER PARTS OF MOUTH MALIGNANT NEOPLASM OF MOUTH, UNSPECIFIED MALIGNANT NEOPLASM OF PAROTID GLAND MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND MALIGNANT NEOPLASM OF SUBLINGUAL GLAND MALIGNANT NEOPLASM OF MAJOR SALIVARY GLAND, UNSPECIFIED MALIGNANT NEOPLASM OF TONSILLAR FOSSA MALIGNANT NEOPLASM OF TONSILLAR PILLAR (ANTERIOR) (POSTERIOR) MALIGNANT NEOPLASM OF OVERLAPPING SITES OF TONSIL MALIGNANT NEOPLASM OF TONSIL, UNSPECIFIED MALIGNANT NEOPLASM OF VALLECULA MALIGNANT NEOPLASM OF ANTERIOR SURFACE OF EPIGLOTTIS MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX 06/18/

38 C104 C108 C109 C110 C111 C112 C113 C118 C119 C12 C130 C131 C132 C138 C139 C140 C142 C148 C153 C154 C155 C158 C159 C160 C161 C162 C163 C164 C165 C166 C168 C169 C170 MALIGNANT NEOPLASM OF BRANCHIAL CLEFT MALIGNANT NEOPLASM OF OVERLAPPING SITES OF OROPHARYNX MALIGNANT NEOPLASM OF OROPHARYNX, UNSPECIFIED 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 OVERLAPPING SITES OF NASOPHARYNX MALIGNANT NEOPLASM OF NASOPHARYNX, UNSPECIFIED MALIGNANT NEOPLASM OF PYRIFORM SINUS MALIGNANT NEOPLASM OF POSTCRICOID REGION MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD, HYPOPHARYNGEAL ASPECT MALIGNANT NEOPLASM OF POSTERIOR WALL OF HYPOPHARYNX MALIGNANT NEOPLASM OF OVERLAPPING SITES OF HYPOPHARYNX MALIGNANT NEOPLASM OF HYPOPHARYNX, UNSPECIFIED MALIGNANT NEOPLASM OF PHARYNX, UNSPECIFIED MALIGNANT NEOPLASM OF WALDEYER'S RING MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LIP, ORAL CAVITY AND PHARYNX MALIGNANT NEOPLASM OF UPPER THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF MIDDLE THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF ESOPHAGUS MALIGNANT NEOPLASM OF ESOPHAGUS, UNSPECIFIED MALIGNANT NEOPLASM OF CARDIA MALIGNANT NEOPLASM OF FUNDUS OF STOMACH MALIGNANT NEOPLASM OF BODY OF STOMACH MALIGNANT NEOPLASM OF PYLORIC ANTRUM MALIGNANT NEOPLASM OF PYLORUS MALIGNANT NEOPLASM OF LESSER CURVATURE OF STOMACH, UNSPECIFIED MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH, UNSPECIFIED MALIGNANT NEOPLASM OF OVERLAPPING SITES OF STOMACH MALIGNANT NEOPLASM OF STOMACH, UNSPECIFIED MALIGNANT NEOPLASM OF DUODENUM 06/18/

39 C171 C172 C173 C178 C179 C180 C181 C182 C183 C184 C185 C186 C187 C188 C189 C19 C20 C210 C211 C212 C218 C220 C221 C222 C223 C224 C227 C228 C229 C23 C240 C241 C248 MALIGNANT NEOPLASM OF JEJUNUM MALIGNANT NEOPLASM OF ILEUM MECKEL'S DIVERTICULUM, MALIGNANT MALIGNANT NEOPLASM OF OVERLAPPING SITES OF SMALL INTESTINE MALIGNANT NEOPLASM OF SMALL INTESTINE, UNSPECIFIED MALIGNANT NEOPLASM OF CECUM MALIGNANT NEOPLASM OF APPENDIX MALIGNANT NEOPLASM OF ASCENDING COLON MALIGNANT NEOPLASM OF HEPATIC FLEXURE MALIGNANT NEOPLASM OF TRANSVERSE COLON MALIGNANT NEOPLASM OF SPLENIC FLEXURE MALIGNANT NEOPLASM OF DESCENDING COLON MALIGNANT NEOPLASM OF SIGMOID COLON MALIGNANT NEOPLASM OF OVERLAPPING SITES OF COLON MALIGNANT NEOPLASM OF COLON, UNSPECIFIED MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION MALIGNANT NEOPLASM OF RECTUM MALIGNANT NEOPLASM OF ANUS, UNSPECIFIED MALIGNANT NEOPLASM OF ANAL CANAL MALIGNANT NEOPLASM OF CLOACOGENIC ZONE MALIGNANT NEOPLASM OF OVERLAPPING SITES OF RECTUM, ANUS AND ANAL CANAL LIVER CELL CARCINOMA INTRAHEPATIC BILE DUCT CARCINOMA HEPATOBLASTOMA ANGIOSARCOMA OF LIVER OTHER SARCOMAS OF LIVER OTHER SPECIFIED CARCINOMAS OF LIVER MALIGNANT NEOPLASM OF LIVER, PRIMARY, UNSPECIFIED AS TO TYPE MALIGNANT NEOPLASM OF LIVER, NOT SPECIFIED AS PRIMARY OR SECONDARY MALIGNANT NEOPLASM OF GALLBLADDER MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCT MALIGNANT NEOPLASM OF AMPULLA OF VATER MALIGNANT NEOPLASM OF OVERLAPPING SITES OF BILIARY TRACT 06/18/

40 C249 C250 C251 C252 C253 C254 C257 C258 C259 C260 C261 C269 C300 C301 C310 C311 C312 C313 C318 C319 C320 C321 C322 C323 C328 C329 C33 C3400 C3401 C3402 C3410 C3411 C3412 C342 MALIGNANT NEOPLASM OF BILIARY TRACT, UNSPECIFIED 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 ENDOCRINE PANCREAS MALIGNANT NEOPLASM OF OTHER PARTS OF PANCREAS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF PANCREAS MALIGNANT NEOPLASM OF PANCREAS, UNSPECIFIED MALIGNANT NEOPLASM OF INTESTINAL TRACT, PART UNSPECIFIED MALIGNANT NEOPLASM OF SPLEEN MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE SYSTEM MALIGNANT NEOPLASM OF NASAL CAVITY MALIGNANT NEOPLASM OF MIDDLE EAR MALIGNANT NEOPLASM OF MAXILLARY SINUS MALIGNANT NEOPLASM OF ETHMOIDAL SINUS MALIGNANT NEOPLASM OF FRONTAL SINUS MALIGNANT NEOPLASM OF SPHENOID SINUS MALIGNANT NEOPLASM OF OVERLAPPING SITES OF ACCESSORY SINUSES MALIGNANT NEOPLASM OF ACCESSORY SINUS, UNSPECIFIED MALIGNANT NEOPLASM OF GLOTTIS MALIGNANT NEOPLASM OF SUPRAGLOTTIS MALIGNANT NEOPLASM OF SUBGLOTTIS MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGE MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LARYNX MALIGNANT NEOPLASM OF LARYNX, UNSPECIFIED MALIGNANT NEOPLASM OF TRACHEA MALIGNANT NEOPLASM OF UNSPECIFIED MAIN BRONCHUS MALIGNANT NEOPLASM OF RIGHT MAIN BRONCHUS MALIGNANT NEOPLASM OF LEFT MAIN BRONCHUS MALIGNANT NEOPLASM OF UPPER LOBE, UNSPECIFIED BRONCHUS OR LUNG MALIGNANT NEOPLASM OF UPPER LOBE, RIGHT BRONCHUS OR LUNG MALIGNANT NEOPLASM OF UPPER LOBE, LEFT BRONCHUS OR LUNG MALIGNANT NEOPLASM OF MIDDLE LOBE, BRONCHUS OR LUNG 06/18/