Erythropoiesis Stimulating Agents (ESAs): Epogen/Procrit (epoetin alfa) (Subcutaneous/Intravenous)

Transcription

1 (Subcutaneus/Intravenus) Last Review Date: January 1, 2019 Number: MG.MM.PH.81 Medical Guideline Disclaimer C All rights reserved. The treating physician r primary care prvider must submit t EmblemHealth the clinical evidence that the patient meets the criteria fr the treatment r surgical prcedure. Withut this dcumentatin and infrmatin, Emb lemhealth will nt be able t prperly review the request fr prir authrizatin. The clinical review criteria expressed belw reflects hw EmblemHealth determines whether certain services r supplies are medically necessary. EmblemHealth established the clinical review criteria based upn a review f currently available clinical infrmatin (including clinical utcme studies in the peer-reviewed published medical literature, regulatry status f the technlgy, evidence-based guidelines f public health and health research agencies, evidence-based guidelines and psitins f leading natinal health prfessinal rganizatins, views f physicians practicing in relevant clinical areas, and ther relevant factrs). EmblemHea lth expressly reserves the right t revise these cnclusins as clinical infrmatin changes, and welcmes further relevant infrmatin. Each benefit prgram defines which services are cvered. The cnclusin that a particular service r supply is medically necessary des nt cnstitute a representatin r warranty that this service r supply is cvered and/r paid fr by EmblemHealth, as sme prgrams exclude cverage fr services r supplies that EmblemHealth cnsiders medically necessary. If there is a discrepancy between this guideline and a member's benefits prgram, the benefits prgram will gvern. In additin, cverage may be mandated by applicable legal requirements f a state, the Federal Gvernment r the Centers fr Medicare & Medicaid Services (CMS) fr Medicare and Medicaid members. All cding and web site links are accurate at time f publicatin. EmblemHealth Services Cmpany LLC, ( EmblemHealth ) has adpted the herein plicy in prviding management, administrative and ther services t HIP Health Plan f New Yrk, HIP Insurance Cmpany f New Yrk, Grup Health Incrprated and GHI HMO Select, related t health benefit plans ffered by these entities. All f the afrementined entities are affiliated cmpanies under cmmn cntrl f EmblemHealth Inc. Related Medical Guideline Off-Label Use f FDA-Apprved Drugs and Bilgicals LENGTH OF AUTHORIZATION Cverage will be prvided fr 60 days and may be renewed. DOSING LIMITS Max Units (per dse and ver time) [Medical Benefit]: MDS and MPN: 120 billable units every 7 days Surgery patients: 600 billable units every 15 days All ther indicatins: Usual: 40 billable units every 7 days Maximum: 60 billable units every 7 days Guideline I. INITIAL APPROVAL CRITERIA Lab values are btained within 30 days f the date f administratin (unless therwise indicated); AND Prir t initiatin f therapy, patient shuld have adequate irn stres as demnstrated by serum ferritin 100 ng/ml (mcg/l) and transferrin saturatin (TSAT) 20%*; AND Initiatin f therapy Hemglbin (Hb) < 10 g/dl and/r Hematcrit (Hct) < 30% (unless therwise specified); AND

2 Page 2 f 13 Other causes f anemia (e.g. hemlysis, bleeding, vitamin deficiency, etc.) have been ruled ut; AND Patient must have a cntraindicatin r intlerance t a trial f epetin alfa-epbx; AND Prcrit/Epgen is cvered fr the fllwing indicatin(s): Anemia secndary t myeldysplastic syndrme (MDS) Treatment f lwer risk disease assciated with symptmatic anemia; AND Endgenus serum erythrpietin level f 500 munits/ml Anemia secndary t Myelprliferative Neplasms (MPN) - Myelfibrsis Endgenus serum erythrpietin level f < 500 munits/ml Anemia secndary t Hepatitis C treatment Patient is receiving interfern AND ribavirin Anemia secndary t rheumatid arthritis Anemia secndary t chemtherapy treatment Patient is receiving cncurrent myelsuppressive chemtherapy; AND Patient s chemtherapy is nt intended t cure their disease (i.e., palliative treatment); AND There are a minimum f tw additinal mnths f planned chemtherapy Anemia secndary t chrnic kidney disease (nn-dialysis patients) Anemia secndary t zidvudine treated, HIV-infected patients Endgenus serum erythrpietin level f 500 munits/ml; AND Patient is receiving zidvudine administered at 4200 mg/week Reductin f allgeneic bld transfusins in elective, nn-cardiac, nn-vascular surgery Hemglbin (Hb) between 10 g/dl and 13 g/dl and/r Hematcrit (Hct) between 30% and 39%; AND Anemia f Prematurity Surgery must be elective, nn-cardiac and nn-vascular Used in cmbinatin with irn supplementatin FDA apprved indicatin(s); Cmpendia recmmended indicatin(s)

3 Page 3 f 13 II. RENEWAL CRITERIA Cverage can be renewed based upn the fllwing criteria: Last dse less than 60 days ag; AND Disease respnse; AND Absence f unacceptable txicity frm the drug. Examples f unacceptable txicity include the fllwing: severe cardivascular events (strke, mycardial infarctin, thrmbemblism, uncntrlled hypertensin), tumr prgressin r recurrence in patients with cancer, seizures, pure red cell aplasia, severe cutaneus reactins (erythema multifrme, Stevens-Jhnsn syndrme/txic epidermal necrlysis), gasping syndrme (central nervus system depressin, metablic acidsis, gasping respiratins) due t benzyl alchl preservative, etc.; AND Lab values are btained within 30 days f the date f administratin (unless therwise indicated); AND Adequate irn stres as demnstrated by serum ferritin 100 ng/ml (mcg/l) and transferrin saturatin (TSAT) 20% measured within the previus 3 mnths*; AND Other causes f anemia (e.g. hemlysis, bleeding, vitamin deficiency, etc.) have been ruled ut; AND Anemia secndary t myeldysplastic syndrme (MDS): Hemglbin (Hb) <12 g/dl and/r Hematcrit (Hct) <36% Anemia secndary t myelprliferative neplasms (MF, pst-pv myelfibrsis, pst-et myelfibrsis) Hemglbin (Hb) <10 g/dl and/r Hematcrit (Hct) <30% Reductin f allgeneic bld transfusins in elective, nn-cardiac, nn-vascular surgery Hemglbin(Hb) between 10 g/dl and 13 g/dl and/r Hematcrit(Hct) between 30% and 39% Anemia secndary t chemtherapy treatment Hemglbin (Hb) <10 g/dl and/r Hematcrit (Hct) < 30%; AND Patient is receiving cncurrent myelsuppressive chemtherapy; AND There are a minimum f tw additinal mnths f planned chemtherapy Anemia secndary t zidvudine treated, HIV-infected patients: Hemglbin (Hb)< 12 g/dl and/r Hematcrit (Hct) < 36%; AND Patient is receiving zidvudine administered at 4200 mg/week Anemia secndary t Hepatitis C treatment: Hemglbin (Hb) < 11 g/dl and/r Hematcrit (Hct) < 33%; AND

4 Page 4 f 13 Patient must be receiving interfern AND ribavirin Anemia secndary t chrnic kidney disease: Pediatric patients: Hemglbin (Hb) < 12 g/dl and/r Hematcrit (Hct) < 36% Adults: Hemglbin (Hb) < 11 g/dl and/r Hematcrit (Hct) < 33% All ther indicatins: Hemglbin (Hb) < 11 g/dl and/r Hematcrit (Hct) < 33% * Intravenus irn supplementatin may be taken int accunt when evaluating irn status Limitatins/Exclusins Epgen/Prcrit is nt cnsidered medically necessary fr indicatins ther than thse listed abve due t insufficient evidence f therapeutic value. Applicable Prcedure Cdes J0885 Q5106 Injectin, epetin alfa, (fr nn-esrd use), 1000 units: 1 billable unit = 1,000 Units Injectin, epetin alfa-epbx, bisimiliar, (Retacrit) (fr nn-esrd use), 1000 units Applicable NDCs xx Epgen 2,000 U/mL single-dse vial slutin fr injectin xx Epgen 3,000 U/mL single-dse vial slutin fr injectin XX Epgen 4,000 U/ml single-dse vial slutin fr injectin XX Epgen 10,000 U/mL single-dse vial slutin fr injectin XX Epgen 10,000 U/mL 2 ml multi-dse vial slutin fr injectin XX Epgen 20,000 U/mL 1 ml multi-dse vial slutin fr injectin XX Prcrit 2,000 U/mL single-dse vial slutin fr injectin XX Prcrit 3,000 U/mL single-dse vial slutin fr injectin XX Prcrit 4,000 U/mL single-dse vial slutin fr injectin XX Prcrit 10,000 U/mL single-dse vial slutin fr injectin XX Prcrit 10,000 U/mL 2 ml multi-dse vial slutin fr injectin XX Prcrit 20,000 U/mL 1 ml multi-dse vial slutin fr injectin XX Prcrit 40,000 U/mL single-dse vial slutin fr injectin XX Retacrit 2,000 U/ml single-dse vial slutin fr injectin XX Retacrit 3,000 U/ml single-dse vial slutin fr injectin XX Retacrit 4,000 U/ml single-dse vial slutin fr injectin XX Retacrit 10,000 U/ml single-dse vial slutin fr injectin XX Retacrit 40,000 U/ml single-dse vial slutin fr injectin

5 Page 5 f 13 Applicable Diagnsis Cdes B18.2 Chrnic viral hepatitis C B19.20 Unspecified viral hepatitis C withut hepatic cma B20 Human immundeficiency virus [HIV] disease C90.00 Multiple myelma nt having achieved remissin C90.01 Multiple myelma in remissin C90.02 Multiple myelma in relapse C90.10 Plasma cell leukemia nt having achieved remissin C90.11 Plasma cell leukemia in remissin C90.12 Plasma cell leukemia, in relapse C90.20 Extramedullary plasmacytma nt having achieved remissin C90.21 Extramedullary plasmacytma in remissin C90.22 Extramedullary plasmacytma in relapse C90.30 Slitary plasmacytma nt having achieved remissin C90.31 Slitary plasmacytma in remissin C90.32 Slitary plasmacytma in relapse C92.10 Chrnic myelid leukemia, BCR/ABL-psitive, nt having achieved remissin C93.10 Chrnic myelmncytic leukemia, nt having achieved remissin C94.40 Acute panmyelsis with myelfibrsis nt having achieved remissin C94.41 Acute panmyelsis with myelfibrsis in remissin C94.42 Acute panmyelsis with myelfibrsis in relapse C94.6 Myeldysplastic disease, nt classified D46.0 Refractry anemia withut ring siderblasts, s stated D46.1 Refractry anemia with ring siderblasts D46.20 Refractry anemia with excess f blasts, unspecified D46.21 Refractry anemia with excess f blasts 1 D46.4 Refractry anemia, unspecified D46.9 Myeldysplastic syndrme, unspecified D46.A Refractry cytpenia with multilineage dysplasia D46.B Refractry cytpenia with multilineage dysplasia and ring siderblasts D46.C Myeldysplastic syndrme with islated del(5q) chrmsmal abnrmality D46.Z Other myeldysplastic syndrmes D47.1 Malignant neplasm f peripheral nerves f upper limb, including shulder D47.4 Malignant neplasm f peripheral nerves f abdmen D61.1 Drug-induced aplastic anemia D61.2 Aplastic anemia due t ther external agent D61.3 Idipathic aplastic anemia D61.89 Other specified aplastic anemias and ther bne marrw failure syndrmes D63.0 Anemia in neplastic disease D63.1 Anemia in chrnic kidney disease D63.8 Anemia in ther chrnic diseases classified elsewhere D64.81 Anemia due t antineplastic chemtherapy D64.9 Anemia unspecified D75.81 Secndary plycythemia I12.0 Hypertensive chrnic kidney disease with stage 5 chrnic kidney disease r end stage renal disease Hypertensive chrnic kidney disease with stage 1 thrugh stage 4 chrnic kidney disease, r I12.9 unspecified chrnic kidney disease Hypertensive heart and chrnic kidney disease with heart failure and stage 1 thrugh stage 4 I13.0 chrnic kidney disease, r unspecified chrnic kidney disease Hypertensive heart and chrnic kidney disease withut heart failure, with stage 1 thrugh stage 4 I13.10 chrnic kidney disease, r unspecified chrnic kidney disease Hypertensive heart and chrnic kidney disease withut heart failure, with stage 5 chrnic kidney I13.11 disease, r end stage renal disease

6 Page 6 f 13 Hypertensive heart and chrnic kidney disease with heart failure and with stage 5 chrnic kidney I13.2 disease, r end stage renal disease M05.10 Rheumatid lung disease with rheumatid arthritis f unspecified site M Rheumatid lung disease with rheumatid arthritis f right shulder M Rheumatid lung disease with rheumatid arthritis f left shulder M Rheumatid lung disease with rheumatid arthritis f unspecified shulder M Rheumatid lung disease with rheumatid arthritis f right elbw M Rheumatid lung disease with rheumatid arthritis f left elbw M Rheumatid lung disease with rheumatid arthritis f unspecified elbw M Rheumatid lung disease with rheumatid arthritis f right wrist M Rheumatid lung disease with rheumatid arthritis f left wrist M Rheumatid lung disease with rheumatid arthritis f unspecified wrist M Rheumatid lung disease with rheumatid arthritis f right hand M Rheumatid lung disease with rheumatid arthritis f left hand M Rheumatid lung disease with rheumatid arthritis f unspecified hand M Rheumatid lung disease with rheumatid arthritis f right hip M Rheumatid lung disease with rheumatid arthritis f left hip M Rheumatid lung disease with rheumatid arthritis f unspecified hip M Rheumatid lung disease with rheumatid arthritis f right knee M Rheumatid lung disease with rheumatid arthritis f left knee M Rheumatid lung disease with rheumatid arthritis f unspecified knee M Rheumatid lung disease with rheumatid arthritis f right ankle and ft M Rheumatid lung disease with rheumatid arthritis f left ankle and ft M Rheumatid lung disease with rheumatid arthritis f unspecified ankle and ft M05.19 Rheumatid lung disease with rheumatid arthritis f multiple sites M05.20 Rheumatid vasculitis with rheumatid arthritis f unspecified site M Rheumatid vasculitis with rheumatid arthritis f right shulder M Rheumatid vasculitis with rheumatid arthritis f left shulder M Rheumatid vasculitis with rheumatid arthritis f unspecified shulder M Rheumatid vasculitis with rheumatid arthritis f right elbw M Rheumatid vasculitis with rheumatid arthritis f left elbw M Rheumatid vasculitis with rheumatid arthritis f unspecified elbw M Rheumatid vasculitis with rheumatid arthritis f right wrist M Rheumatid vasculitis with rheumatid arthritis f left wrist M Rheumatid vasculitis with rheumatid arthritis f unspecified wrist M Rheumatid vasculitis with rheumatid arthritis f right hand M Rheumatid vasculitis with rheumatid arthritis f left hand M Rheumatid vasculitis with rheumatid arthritis f unspecified hand M Rheumatid vasculitis with rheumatid arthritis f right hip M Rheumatid vasculitis with rheumatid arthritis f left hip M Rheumatid vasculitis with rheumatid arthritis f unspecified hip M Rheumatid vasculitis with rheumatid arthritis f right knee M Rheumatid vasculitis with rheumatid arthritis f left knee M Rheumatid vasculitis with rheumatid arthritis f unspecified knee M Rheumatid vasculitis with rheumatid arthritis f right ankle and ft M Rheumatid vasculitis with rheumatid arthritis f left ankle and ft M Rheumatid vasculitis with rheumatid arthritis f unspecified ankle and ft M05.29 Rheumatid vasculitis with rheumatid arthritis f multiple sites M05.30 Rheumatid heart disease with rheumatid arthritis f unspecified site M Rheumatid heart disease with rheumatid arthritis f right shulder M Rheumatid heart disease with rheumatid arthritis f left shulder M Rheumatid heart disease with rheumatid arthritis f unspecified shulder M Rheumatid heart disease with rheumatid arthritis f right elbw M Rheumatid heart disease with rheumatid arthritis f left elbw

7 Page 7 f 13 M Rheumatid heart disease with rheumatid arthritis f unspecified elbw M Rheumatid heart disease with rheumatid arthritis f right wrist M Rheumatid heart disease with rheumatid arthritis f left wrist M Rheumatid heart disease with rheumatid arthritis f unspecified wrist M Rheumatid heart disease with rheumatid arthritis f right hand M Rheumatid heart disease with rheumatid arthritis f left hand M Rheumatid heart disease with rheumatid arthritis f unspecified hand M Rheumatid heart disease with rheumatid arthritis f right hip M Rheumatid heart disease with rheumatid arthritis f left hip M Rheumatid heart disease with rheumatid arthritis f unspecified hip M Rheumatid heart disease with rheumatid arthritis f right knee M Rheumatid heart disease with rheumatid arthritis f left knee M Rheumatid heart disease with rheumatid arthritis f unspecified knee M Rheumatid heart disease with rheumatid arthritis f right ankle and ft M Rheumatid heart disease with rheumatid arthritis f left ankle and ft M Rheumatid heart disease with rheumatid arthritis f unspecified ankle and ft M05.39 Rheumatid heart disease with rheumatid arthritis f multiple sites M05.40 Rheumatid mypathy with rheumatid arthritis f unspecified site M Rheumatid mypathy with rheumatid arthritis f right shulder M Rheumatid mypathy with rheumatid arthritis f left shulder M Rheumatid mypathy with rheumatid arthritis f unspecified shulder M Rheumatid mypathy with rheumatid arthritis f right elbw M Rheumatid mypathy with rheumatid arthritis f left elbw M Rheumatid mypathy with rheumatid arthritis f unspecified elbw M Rheumatid mypathy with rheumatid arthritis f right wrist M Rheumatid mypathy with rheumatid arthritis f left wrist M Rheumatid mypathy with rheumatid arthritis f unspecified wrist M Rheumatid mypathy with rheumatid arthritis f right hand M Rheumatid mypathy with rheumatid arthritis f left hand M Rheumatid mypathy with rheumatid arthritis f unspecified hand M Rheumatid mypathy with rheumatid arthritis f right hip M Rheumatid mypathy with rheumatid arthritis f left hip M Rheumatid mypathy with rheumatid arthritis f unspecified hip M Rheumatid mypathy with rheumatid arthritis f right knee M Rheumatid mypathy with rheumatid arthritis f left knee M Rheumatid mypathy with rheumatid arthritis f unspecified knee M Rheumatid mypathy with rheumatid arthritis f right ankle and ft M Rheumatid mypathy with rheumatid arthritis f left ankle and ft M Rheumatid mypathy with rheumatid arthritis f unspecified ankle and ft M05.49 Rheumatid mypathy with rheumatid arthritis f multiple sites M05.50 Rheumatid plyneurpathy with rheumatid arthritis f unspecified site M Rheumatid plyneurpathy with rheumatid arthritis f right shulder M Rheumatid plyneurpathy with rheumatid arthritis f left shulder M Rheumatid plyneurpathy with rheumatid arthritis f unspecified shulder M Rheumatid plyneurpathy with rheumatid arthritis f right elbw M Rheumatid plyneurpathy with rheumatid arthritis f left elbw M Rheumatid plyneurpathy with rheumatid arthritis f unspecified elbw M Rheumatid plyneurpathy with rheumatid arthritis f right wrist M Rheumatid plyneurpathy with rheumatid arthritis f left wrist M Rheumatid plyneurpathy with rheumatid arthritis f unspecified wrist M Rheumatid plyneurpathy with rheumatid arthritis f right hand M Rheumatid plyneurpathy with rheumatid arthritis f left hand M Rheumatid plyneurpathy with rheumatid arthritis f unspecified hand M Rheumatid plyneurpathy with rheumatid arthritis f right hip

8 Page 8 f 13 M Rheumatid plyneurpathy with rheumatid arthritis f left hip M Rheumatid plyneurpathy with rheumatid arthritis f unspecified hip M Rheumatid plyneurpathy with rheumatid arthritis f right knee M Rheumatid plyneurpathy with rheumatid arthritis f left knee M Rheumatid plyneurpathy with rheumatid arthritis f unspecified knee M Rheumatid plyneurpathy with rheumatid arthritis f right ankle and ft M Rheumatid plyneurpathy with rheumatid arthritis f left ankle and ft M Rheumatid plyneurpathy with rheumatid arthritis f unspecified ankle and ft M05.59 Rheumatid plyneurpathy with rheumatid arthritis f multiple sites M05.60 Rheumatid arthritis f unspecified site with invlvement f ther rgans and systems M Rheumatid arthritis f right shulder with invlvement f ther rgans and systems M Rheumatid arthritis f left shulder with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified shulder with invlvement f ther rgans and systems M Rheumatid arthritis f right elbw with invlvement f ther rgans and systems M Rheumatid arthritis f left elbw with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified elbw with invlvement f ther rgans and systems M Rheumatid arthritis f right wrist with invlvement f ther rgans and systems M Rheumatid arthritis f left wrist with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified wrist with invlvement f ther rgans and systems M Rheumatid arthritis f right hand with invlvement f ther rgans and systems M Rheumatid arthritis f left hand with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified hand with invlvement f ther rgans and systems M Rheumatid arthritis f right hip with invlvement f ther rgans and systems M Rheumatid arthritis f left hip with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified hip with invlvement f ther rgans and systems M Rheumatid arthritis f right knee with invlvement f ther rgans and systems M Rheumatid arthritis f left knee with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified knee with invlvement f ther rgans and systems M Rheumatid arthritis f right ankle and ft with invlvement f ther rgans and systems M Rheumatid arthritis f left ankle and ft with invlvement f ther rgans and systems M Rheumatid arthritis f unspecified ankle and ft with invlvement f ther rgans and systems M05.69 Rheumatid arthritis f multiple sites with invlvement f ther rgans and systems Rheumatid arthritis with rheumatid factr f unspecified site withut rgan r systems M05.70 invlvement Rheumatid arthritis with rheumatid factr f right shulder withut rgan r systems M invlvement Rheumatid arthritis with rheumatid factr f left shulder withut rgan r systems M invlvement Rheumatid arthritis with rheumatid factr f unspecified shulder withut rgan r systems M invlvement M Rheumatid arthritis with rheumatid factr f right elbw withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f left elbw withut rgan r systems invlvement Rheumatid arthritis with rheumatid factr f unspecified elbw withut rgan r systems M invlvement M Rheumatid arthritis with rheumatid factr f right wrist withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f left wrist withut rgan r systems invlvement Rheumatid arthritis with rheumatid factr f unspecified wrist withut rgan r systems M invlvement M Rheumatid arthritis with rheumatid factr f right hand withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f left hand withut rgan r systems invlvement Rheumatid arthritis with rheumatid factr f unspecified hand withut rgan r systems M invlvement M Rheumatid arthritis with rheumatid factr f right hip withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f left hip withut rgan r systems invlvement

9 Page 9 f 13 Rheumatid arthritis with rheumatid factr f unspecified hip withut rgan r systems M invlvement M Rheumatid arthritis with rheumatid factr f right knee withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f left knee withut rgan r systems invlvement Rheumatid arthritis with rheumatid factr f unspecified knee withut rgan r systems M invlvement Rheumatid arthritis with rheumatid factr f right ankle and ft withut rgan r systems M invlvement Rheumatid arthritis with rheumatid factr f left ankle and ft withut rgan r systems M invlvement Rheumatid arthritis with rheumatid factr f unspecified ankle and ft withut rgan r M systems invlvement Rheumatid arthritis with rheumatid factr f multiple sites withut rgan r systems M05.79 invlvement M05.80 Other rheumatid arthritis with rheumatid factr f unspecified site M Other rheumatid arthritis with rheumatid factr f right shulder M Other rheumatid arthritis with rheumatid factr f left shulder M Other rheumatid arthritis with rheumatid factr f unspecified shulder M Other rheumatid arthritis with rheumatid factr f right elbw M Other rheumatid arthritis with rheumatid factr f left elbw M Other rheumatid arthritis with rheumatid factr f unspecified elbw M Other rheumatid arthritis with rheumatid factr f right wrist M Other rheumatid arthritis with rheumatid factr f left wrist M Other rheumatid arthritis with rheumatid factr f unspecified wrist M Other rheumatid arthritis with rheumatid factr f right hand M Other rheumatid arthritis with rheumatid factr f left hand M Other rheumatid arthritis with rheumatid factr f unspecified hand M Other rheumatid arthritis with rheumatid factr f right hip M Other rheumatid arthritis with rheumatid factr f left hip M Other rheumatid arthritis with rheumatid factr f unspecified hip M Other rheumatid arthritis with rheumatid factr f right knee M Other rheumatid arthritis with rheumatid factr f left knee M Other rheumatid arthritis with rheumatid factr f unspecified knee M Other rheumatid arthritis with rheumatid factr f right ankle and ft M Other rheumatid arthritis with rheumatid factr f left ankle and ft M Other rheumatid arthritis with rheumatid factr f unspecified ankle and ft M05.89 Other rheumatid arthritis with rheumatid factr f multiple sites M05.9 Rheumatid arthritis with rheumatid factr, unspecified M06.00 Rheumatid arthritis withut rheumatid factr, unspecified site M Rheumatid arthritis withut rheumatid factr, right shulder M Rheumatid arthritis withut rheumatid factr, left shulder M Rheumatid arthritis withut rheumatid factr, unspecified shulder M Rheumatid arthritis withut rheumatid factr, right elbw M Rheumatid arthritis withut rheumatid factr, left elbw M Rheumatid arthritis withut rheumatid factr, unspecified elbw M Rheumatid arthritis withut rheumatid factr, right wrist M Rheumatid arthritis withut rheumatid factr, left wrist M Rheumatid arthritis withut rheumatid factr, unspecified wrist M Rheumatid arthritis withut rheumatid factr, right hand M Rheumatid arthritis withut rheumatid factr, left hand M Rheumatid arthritis withut rheumatid factr, unspecified hand M Rheumatid arthritis withut rheumatid factr, right hip M Rheumatid arthritis withut rheumatid factr, left hip M Rheumatid arthritis withut rheumatid factr, unspecified hip

10 Page 10 f 13 M Rheumatid arthritis withut rheumatid factr, right knee M Rheumatid arthritis withut rheumatid factr, left knee M Rheumatid arthritis withut rheumatid factr, unspecified knee M Rheumatid arthritis withut rheumatid factr, right ankle and ft M Rheumatid arthritis withut rheumatid factr, left ankle and ft M Rheumatid arthritis withut rheumatid factr, unspecified ankle and ft M06.08 Rheumatid arthritis withut rheumatid factr, vertebrae M06.09 Rheumatid arthritis withut rheumatid factr, multiple sites M06.80 Other specified rheumatid arthritis, unspecified site M Other specified rheumatid arthritis, right shulder M Other specified rheumatid arthritis, left shulder M Other specified rheumatid arthritis, unspecified shulder M Other specified rheumatid arthritis, right elbw M Other specified rheumatid arthritis, left elbw M Other specified rheumatid arthritis, unspecified elbw M Other specified rheumatid arthritis, right wrist M Other specified rheumatid arthritis, left wrist M Other specified rheumatid arthritis, unspecified wrist M Other specified rheumatid arthritis, right hand M Other specified rheumatid arthritis, left hand M Other specified rheumatid arthritis, unspecified hand M Other specified rheumatid arthritis, right hip M Other specified rheumatid arthritis, left hip M Other specified rheumatid arthritis, unspecified hip M Other specified rheumatid arthritis, right knee M Other specified rheumatid arthritis, left knee M Other specified rheumatid arthritis, unspecified knee M Other specified rheumatid arthritis, right ankle and ft M Other specified rheumatid arthritis, left ankle and ft M Other specified rheumatid arthritis, unspecified ankle and ft M06.88 Other specified rheumatid arthritis, vertebrae M06.89 Other specified rheumatid arthritis, multiple sites M06.9 Rheumatid arthritis, unspecified N18.1 Chrnic kidney disease, stage 1 N18.2 Chrnic kidney disease, stage 2 (mild) N18.3 Chrnic kidney disease, stage 3 (mderate) N18.4 Chrnic kidney disease, stage 4 (severe) N18.5 Chrnic kidney disease, stage 5 N18.6 End stage renal disease N18.9 Chrnic kidney disease, unspecified P07.20 Extreme immaturity f newbrn unspecified weeks f gestatin P07.21 Extreme immaturity f newbrn gestatinal age less than 23 cmpleted weeks P07.22 Extreme immaturity f newbrn gestatinal age 23 cmpleted weeks P07.23 Extreme immaturity f newbrn gestatinal age 24 cmpleted weeks P07.24 Extreme immaturity f newbrn gestatinal age 25 cmpleted weeks P07.25 Extreme immaturity f newbrn gestatinal age 26 cmpleted weeks P07.26 Extreme immaturity f newbrn gestatinal age 27 cmpleted weeks P07.30 Preterm newbrn, unspecified weeks f gestatin P07.31 Preterm newbrn, gestatinal age 28 cmpleted weeks P07.32 Preterm newbrn, gestatinal age 29 cmpleted weeks P07.33 Preterm newbrn, gestatinal age 30 cmpleted weeks P07.34 Preterm newbrn, gestatinal age 31 cmpleted weeks P07.35 Preterm newbrn, gestatinal age 32 cmpleted weeks P07.36 Preterm newbrn, gestatinal age 33 cmpleted weeks

11 Page 11 f 13 P07.37 Preterm newbrn, gestatinal age 34 cmpleted weeks P07.38 Preterm newbrn, gestatinal age 35 cmpleted weeks P07.39 Preterm newbrn, gestatinal age 36 cmpleted weeks T37.5X5A Adverse effect f antiviral drugs, initial encunter T37.5X5D Adverse effect f antiviral drugs subsequent encunter T37.5X5S Adverse effect f antiviral drugs sequela Z21 Asymptmatic human immundeficiency virus [HIV] infectin status Z41.8 Encunter fr ther prcedures fr purpses ther than remedying health state Z51.11 Encunter fr antineplastic chemtherapy Z51.89 Encunter fr ther specified aftercare DUAL CODING REQUIREMENTS: J0885 MUST BE BILLED IN CONJUNCTION WITH BOTH D63.8 OR D64.9 AND Z41.8 FOR PREOPERATIVE USE. J0885 must be billed in cnjunctin with BOTH D63.1 AND ne f the I r N series f cdes fr CKD nt n dialysis J0885 must be billed in cnjunctin with BOTH D61.1-D61.3, D61.89, r D64.9 AND B20 fr anemia due t HIV J0885 must be billed in cnjunctin with BOTH D63.8 r D64.9 AND either B18.2 r B19.20 fr anemia due t HCV J0885 must be billed in cnjunctin with BOTH D63.8 r D64.9 AND a cde frm the M series fr anemia due t RA Revisin Histry N/A References 1. Prcrit [package insert]. Hrsham, PA; Janssen Prducts, LP; September Accessed March Epgen [package insert]. Thusand Oaks, CA; Amgen, Inc; September Accessed March Referenced with permissin frm the NCCN Drugs & Bilgics Cmpendium (NCCN Cmpendium ) epetin alfa. Natinal Cmprehensive Cancer Netwrk, The NCCN Cmpendium is a derivative wrk f the NCCN Guidelines. NATIONAL COMPREHENSIVE CANCER NETWORK, NCCN, and NCCN GUIDELINES are trademarks wned by the Natinal Cmprehensive Cancer Netwrk, Inc. T view the mst recent and cmplete versin f the Cmpendium, g nline t NCCN.rg. Accessed March Referenced with permissin frm the NCCN Drugs & Bilgics Cmpendium (NCCN Cmpendium ) Cancer-and Chemtherapy-Induced Anemia Versin Natinal Cmprehensive Cancer Netwrk, The NCCN Cmpendium is a derivative wrk f the NCCN Guidelines. NATIONAL COMPREHENSIVE CANCER NETWORK, NCCN, and NCCN GUIDELINES are trademarks wned by the Natinal Cmprehensive Cancer Netwrk, Inc. T view the mst recent and cmplete versin f the Cmpendium, g nline t NCCN.rg. Accessed March Referenced with permissin frm the NCCN Drugs & Bilgics Cmpendium (NCCN Cmpendium ) Myeldysplastic Syndrme Versin Natinal Cmprehensive Cancer Netwrk, The NCCN Cmpendium is a derivative wrk f the NCCN Guidelines. NATIONAL COMPREHENSIVE CANCER NETWORK, NCCN, and NCCN GUIDELINES are

12 Page 12 f 13 trademarks wned by the Natinal Cmprehensive Cancer Netwrk, Inc. T view the mst recent and cmplete versin f the Cmpendium, g nline t NCCN.rg. Accessed March Referenced with permissin frm the NCCN Drugs & Bilgics Cmpendium (NCCN Cmpendium ) Myelprliferative Neplasms Versin Natinal Cmprehensive Cancer Netwrk, The NCCN Cmpendium is a derivative wrk f the NCCN Guidelines. NATIONAL COMPREHENSIVE CANCER NETWORK, NCCN, and NCCN GUIDELINES are trademarks wned by the Natinal Cmprehensive Cancer Netwrk, Inc. T view the mst recent and cmplete versin f the Cmpendium, g nline t NCCN.rg. Accessed March Peeters, HR, Jngen-Lavrencic, M, Vreugdenhil, G, Swaak, AJ. Effect f recmbinant human erythrpietin n anaemia and disease activity in patients with rheumatid arthritis and anaemia f chrnic disease: a randmized placeb cntrlled duble blind 52 weeks clinical trial. Ann Rheum Dis 1996; 55: Pincus T, Olsen NJ, Russell IJ, et al. Multicenter study f recmbinant human erythrpietin in crrectin f anemia in rheumatid arthritis. Am J Med 1990; 89: Saag, MS, Bwers, P, Leitz, GJ, Levine, AM. Once-weekly epetin alfa imprves quality f life and increases hemglbin in anemic HIV+ patients. AIDS Res Hum Retrviruses 2004; 20: Grssman, HA, Gn, B, Bwers, P, Leitz, G. Once-weekly epetin alfa dsing is as effective as three times-weekly dsing in increasing hemglbin levels and is assciated with imprved quality f life in anemic HIV-infected patients. J Acquir Immune Defic Syndr 2003; 34: Afdhal, NH, Dieterich, DT, Pckrs, PJ, et al. Epetin alfa maintains ribavirin dse in HCV-infected patients: a prspective, duble-blind, randmized cntrlled study. Gastrenterlgy 2004; 126: Cervantes F, Alvarez-Laran A, Hernandez-Bluda JC, et al. Erythrpietin treatment f the anaemia f myelfibrsis with myelid metaplasia: results in 20 patients and review f the literature. British Jurnal f Haematlgy, 127: di: /j x 13. Shaffer CL, Ransm JL. Current and theretical cnsideratins f erythrpietin use in anemia f brnchpulmnary dysplasia. J f Pediatric Pharmacy Practice 1996; 1: Reiter PD, Rsenberg AA, Valuck RJ. Factrs assciated with successful epetin alfa therapy in premature infants. Ann Pharmacther 2000; 34: Wiscnsin Physicians Service Insurance Crpratin. Lcal Cverage Determinatin (LCD): Erythrpiesis Stimulating Agents - Epetin alfa, Epetin beta, Darbepetin alfa, Peginesatide (L34633). Centers fr Medicare & Medicaid Services, Inc. Updated n 09/20/2017 with effective dates 10/1/2017. Accessed March CGS Administratrs, Inc. Lcal Cverage Determinatin (LCD): Erythrpiesis Stimulating Agents (ESAs) (L34356). Centers fr Medicare & Medicare Services. Updated n 02/26/2018 with effective dates 10/01/2017. Accessed March 2018.

13 Page 13 f First Cast Service Optins, Inc. Lcal Cverage Determinatin (LCD): Erythrpiesis Stimulating Agents (ESAs) (L36276). Centers fr Medicare & Medicare Services. Updated n 02/22/2018 with effective dates 02/08/2018. Accessed March Natinal Cverage Determinatin (NCD) fr Erythrpiesis Stimulating Agents (ESAs) in Cancer and Related Neplastic Cnditins (110.21). Centers fr Medicare & Medicare Services, Inc. Updated 12/3/2015 with an effective date 10/1/2015. Accessed March 2018.