Rituxan (rituximab) Document Number: IC-0109

Transcription

1 Rituxan (rituximab) Dcument Number: IC-0109 Last Review Date: 10/31/2017 Date f Origin: 7/20/2010 Dates Reviewed: 09/2010, 12/2010, 02/2011, 03/2011, 05/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 12/2012, 03/2013, 06/2013, 09/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 05/2015, 08/2015, 11/2015, 02/2016, 05/2016, 08/2016, 10/2016, 02/2017, 05/2017, 08/2017, 10/2017 I. Length f Authrizatin Cverage will be prvided fr 6 mnths and may be renewed unless therwise specified. Maintenance therapy fr nclgy indicatins (excluding ALL) may be renewed fr up t a maximum f 2 years. Acute lymphblastic leukemia (ALL) may nt be renewed. II. Dsing Limits A. Quantity Limit (max daily dse) [Pharmacy Benefit]: Rituxan 100 mg/10 ml injectin: 12 vials per 28 day supply Rituxan 500 mg/50 ml injectin: 8 vials per 28 day supply B. Max Units (per dse and ver time) [Medical Benefit]: Onclgy Indicatins Chrnic Lymphcytic Leukemia (CLL)/Small Lymphcytic Leukemia (SLL): Initial therapy: Lading dse: 10 units x 1 dse Subsequent dses: 13 units every 28 days x 5 dses per 6 mnths Renewal therapy: 10 units per dse every 8 weeks x 4 dses per 6 mnths All ther nclgy indicatins: Initial therapy: 10 units per dse weekly x 8 dses per 6 mnths Renewal therapy: 10 units per dse every 8 weeks x 4 dses per 6 mnths Nn-Onclgy Indicatins Rheumatid Arthritis (RA): 10 units per dse every 14 days x 2 dses in a 16 week perid cgvhd 10 units per dse weekly x 4 dses, then 10 units mnthly x 4 mnths All ther nn-nclgy indicatins: 10 units per dse weekly x 4 dses in a 6 mnth perid III. Initial Apprval Criteria Cverage is prvided in the fllwing cnditins: Mda Health Plan, Inc. Medical Necessity Criteria Page 1/19

2 Patient must be screened fr HBV infectin (i.e., HBsAg and anti-hbc) prir t initiating therapy; AND Onclgy Indicatins: Patient is CD20-psitive; AND Acute Lymphblastic Leukemia (ALL) Inductin Treatment Patient s disease is Philadelphia chrmsme-negative (Ph-); AND Patient is at least 15 years f age; AND Used in cmbinatin with an anthracycline, cyclphsphamide and vincristine based regimen Relapsed-Refractry Treatment Used as a cmpnent f MOpAD regimen (methtrexate, vincristine, pegaspargase, dexamethasne); AND CNS Cancer Patient s disease is Philadelphia chrmsme-negative (Ph-); OR Patient s disease is Philadelphia chrmsme-psitive (Ph+) and refractry t tyrsine kinase inhibitrs (e.g.; macetaxine, imatinib, bsutinib, pnatinib, niltinib, etc.) Patient has leptmeningeal metastases frm lymphmas; AND Rituximab will be administered intrathecally; OR Patient has primary CNS lymphma; AND Patient will receive in cmbinatin with a methtrexate-cntaining regimen as a cmpnent f inductin therapy and/r cnslidatin therapy with a cmplete respnse t inductin therapy; OR Patient has relapsed r refractry disease and will receive rituximab as a single agent r in cmbinatin with temzlmide Hdgkin s lymphma Patient has ndular lymphcyte-predminant disease Chrnic lymphcytic leukemia/small lymphcytic lymphma (CLL/SLL) Waldenström s macrglbulinemia/lymphplasmacytic Lymphma Nn-Hdgkin s lymphmas (NHL) including, but nt limited t, the fllwing: AIDS-related B-Cell Lymphma Burkitt Lymphma Castleman s Disease Diffuse Large B-Cell Lymphma Lw-grade r Fllicular Lymphma Gastric & Nn-gastric Malt Lymphma Hairy Cell Leukemia Mda Health Plan, Inc. Medical Necessity Criteria Page 2/19

3 Mantle Cell Lymphma Ndal Marginal Zne Lymphma Pst-transplant lymphprliferative disrder (PTLD) Patient has had slid rgan transplant r allgeneic hematpietic stem cell transplantatin Primary Cutaneus B-Cell Lymphmas Splenic Marginal Zne Lymphma Nn-Onclgy Indicatins: Rheumatid arthritis (RA) Adult patient (18 years r lder); AND Dcumented mderate t severe disease; AND Must be used in cmbinatin with methtrexate unless the patient has a cntraindicatin r intlerance; AND Patient tried and failed at least a 3 mnth trial with ONE ral disease mdifying antirheumatic drug (DMARD) (e.g., methtrexate, azathiprine, auranfin, hydrxychlrquine, penicillamine, sulfasalazine, leflunmide, etc.); AND Previus failure with ne r mre preferred TNF antagnists at least ne f which shuld be a self-injectable; AND Patient has nt had treatment with Rituxan in the previus 4 mnths Pemphigus vulgaris Patient has failed previus cnventinal therapy with crticsterids and/r azathiprine Granulmatsis with Plyangiitis (GPA) (Wegener s granulmatsis) and Micrscpic plyangiitis (MPA) Adult patient (18 years r lder); AND Used in cmbinatin with gluccrticids Thrmbcytpenic purpura Patient diagnsis includes ne f the fllwing: Primary thrmbcytpenia Idipathic (Immune) thrmbcytpenia purpura (ITP) Evan s syndrme Cngenital and hereditary thrmbcytpenic purpura Thrmbtic thrmbcytpenic purpura in patients with ADAMTS13-deficiency Chrnic graft-versus-hst disease (cgvhd) Patient is pst-allgeneic stem cell transplant; AND Patient has gluccrticid-refractry disease Autimmune Hemlytic Anemia (AIHA) Patient has warm-reactive disease refractry t r dependent n gluccrticids; OR Mda Health Plan, Inc. Medical Necessity Criteria Page 3/19

4 Patient has cld agglutinin disease with symptmatic anemia, transfusin-dependence, and/r disabling circulatry symptms FDA-labeled indicatin(s); Cmpendia recmmended indicatin(s) IV. Renewal Criteria Cverage can be renewed based upn the fllwing criteria: Patient cntinues t meet criteria identified in sectin III; AND Absence f unacceptable txicity frm the drug. Examples f unacceptable txicity include the fllwing: severe infusin reactins, tumr lysis syndrme (TLS), severe muccutaneus reactins, prgressive multifcal leukencephalpathy (PML), viral hepatitis, serius bacterial, fungal, r viral infectins, cardiac arrhythmias, renal txicity, bwel bstructin r perfratin; AND Onclgy Indicatins: Tumr respnse with stabilizatin f disease r decrease in size f tumr r tumr spread; AND Patient has nt exceeded dsing r duratin limits as defined in Sectins I, II, and V Nn-Onclgy Indicatins: Rheumatid arthritis (RA) Disease respnse as indicated by imprvement in signs and cmpared t baseline such as the number f tender and swllen jint cunts. Thrmbcytpenic purpura Disease respnse as indicated by the achievement and maintenance f a platelet cunt f at least /L as necessary t reduce the risk fr bleeding Thrmbtic thrmbcytpenic purpura (TTP) Disease respnse as indicated by an increase in ADAMTS13 activity with a reductin in thrmbsis risk Pemphigus vulgaris, Granulmatsis with Plyangiitis (GPA) (Wegener s granulmatsis) and Micrscpic plyangiitis (MPA) Disease respnse as indicated by imprvement in signs and symptms f cnditin cmpared t baseline Chrnic graft-versus-hst disease (cgvhd) Disease respnse as indicated by imprvement in patient-reprted symptms r clinician assessments (e.g., manifestatins f disease t the skin, ral cavity, musculskeletal system, etc.) Autimmune hemlytic anemia (AIHA) Disease respnse as indicated by imprvement in anemia signs and symptms (e.g., dyspnea, fatigue, etc.) as well as: imprvement in labratry values (Hb/Hct), reduced transfusin needs, and/r reduced gluccrticid use Mda Health Plan, Inc. Medical Necessity Criteria Page 4/19

5 V. Dsage/Administratin Indicatin CLL/SLL NHL, CNS Lymphma, PTLD, Waldenström s, Castleman s, r HL ALL RA Initial Therapy Dse 375 mg/m² weekly x 8 dses; OR 375 mg/m² cycle 1, then 500 mg/m² every 28 days cycles 2-6 (6 ttal dses) 375 mg/m² nce weekly fr 4 dses per 6 mnth perid; OR Renewal Therapy 375 mg/ m² every 8 weeks Initial Therapy 375 mg/m 2 nce weekly fr 4-8 dses in a 6 mnth perid 375 mg/m² nce weekly fr 4 dses per 6 mnth perid; OR Renewal Therapy 375 mg/ m² every 8 weeks 375 mg/m 2 nce weekly fr 4-8 dses in a 6 mnth perid 1,000 mg n days 1 and 15, repeated up t every 16 weeks Pemphigus, Thrmbcytpenia, GPA, WG, MPA, r AIHA cgvhd 375 mg/m² weekly x 4 dses in a 6 mnth perid 375 mg/m² weekly x 4 dses, then 375 mg/m² mnthly x 4 mnths VI. Billing Cde/Availability Infrmatin JCde: J9310 Injectin, rituximab, 100 mg; 1 billable unit = 100 mg NDC: Rituxan 100 mg/10 ml single-use vial fr injectin: xx Rituxan 500 mg/50 ml single-use vial fr injectin: xx VII. References 1. Rituxan [package insert]. Suth San Francisc, CA; Genentech, Inc; April Accessed September Referenced with permissin frm the NCCN Drugs & Bilgics Cmpendium (NCCN Cmpendium ) rituximab. 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 September Arnld DM, Dentali F, Crwther MA, et al. Systematic review: efficacy and safety f rituximab fr adults with idipathic thrmbcytpenic purpura. Ann Intern Med 2007; 146: Zaja F, Baccarani M, Mazza P, et al: Dexamethasne plus rituximab yields higher sustained respnse rates than dexamethasne mntherapy in adults with primary immune thrmbcytpenia. Bld 2010; 115(14): Mda Health Plan, Inc. Medical Necessity Criteria Page 5/19

6 5. Stasi R, Pagan A, Stipa E, et al: Rituximab chimeric anti-cd10 mnclnal antibdy treatment fr adults with chrnic idipathic thrmbcytpenic purpura. Bld 2001; 98(4): Neunert C, Lim W, Crwther M, Chen A, Slberg L Jr, Crwther MA. The American Sciety f Hematlgy 2011 evidence-based practice guideline fr immune thrmbcytpenia. Bld. 117(16): Jly P, Muquet H, Rujeau JC, et al. A single cycle f rituximab fr the treatment f severe pemphigus. N Engl J Med 2007; 357: Ahmed AR, Spigelman Z, Cavacini LA et al. Treatment f pemphigus vulgaris with rituximab and intravenus immune glbulin. N Engl J Med 2006; 355: Singh JA, Saag KG, Bridges SL Jr, et al American Cllege f Rheumatlgy Guideline fr the Treatment f Rheumatid Arthritis. Arthritis Care Res (Hbken) Nv 6. di: /acr Smlen JS, Landewé R, Bijlsma J, et al. EULAR recmmendatins fr the management f rheumatid arthritis with synthetic and bilgical disease-mdifying antirheumatic drugs: 2016 update. Ann Rheum Dis Mar 6. pii: annrheumdis Gnzález-Barca E, Dming-Dmenech E, Capte FJ, et al. Prspective phase II trial f extended treatment with rituximab in patients with B-cell pst-transplant lymphprliferative disease. Haematlgica Nv; 92(11): Chamberlain MC, Jhnstn SK, Van Hrn A, et al. Recurrent lymphmatus meningitis treated with intra-csf rituximab and lipsmal ara-c. J Neurncl Feb;91(3): Scully M, Chen H, Cavenagh J, et al. Remissin in acute refractry and relapsing thrmbtic thrmbcytpenic purpura fllwing rituximab is assciated with a reductin in IgG antibdies t ADAMTS-13. Br J Haematl 2007;136: Fakhuri F, Vernant JP, Veyradier A, et al. Efficiency f curative and prphylactic treatment with rituximab in ADAMTS13-deficient thrmbtic thrmbcytpenic purpura: a study f 11 cases. Bld. 2005;106: Ellitt MA, Heit JA, Rajiv K, et al. Rituximab fr refractry and r relapsing thrmbtic thrmbcytpenic purpura related t immune-mediated severe ADAMTS13-deficiency: a reprt f fur cases and a systematic review f the literature. Eur J Haematl Epub ahead f print, di: /j Scully M, McDnald V, Cavenagh J, et al. A phase 2 study f the safety and efficacy f rituximab with plasma exchange in acute acquired thrmbtic thrmbcytpenic purpura. Bld. 2011;118(7): Tun NM, Villani GM. Efficacy f rituximab in acute refractry r chrnic relapsing nnfamilial idipathic thrmbtic thrmbcytpenic purpura: a systematic review with pled data analysis. J Thrmb Thrmblysis. 2012;34(3): Frissart A, Buffet M, Veyradier A, et al: Efficacy and safety f first-line rituximab in severe, acquired thrmbtic thrmbcytpenic purpura with a subptimal respnse t plasma exchange. Experience f the French Thrmbtic Micrangipathies Reference Center. Crit Care Med 2012; 40(1): Mda Health Plan, Inc. Medical Necessity Criteria Page 6/19

7 19. van Drp S, Resemann H, te Bme L, et al. The immunlgical phentype f rituximabsensitive chrnic graft-versus-hst disease: a phase II study. Haematlgica 2011;96(9): Kim SJ, Lee JW, Jung CW, et al. Weekly rituximab fllwed by mnthly rituximab treatment fr sterid-refractry chrnic graft-versus-hst disease: results frm a prspective, multicenter, phase II study. Haematlgica 2010;95(11): Cutler C, Mikls D, Kim HT, et al, Rituximab fr Sterid-Refractry Chrnic Graft-Versus- Hst Disease, Bld, 2006, 108(2): Wlff D, Schleuning M, vn Harsdrf S, et al. Cnsensus Cnference n Clinical Practice in Chrnic GVHD: Secnd-Line Treatment f Chrnic Graft-versus-Hst Disease. Bil Bld Marrw Transplant Jan;17(1):1-17. di: /j.bbmt Frame JN, Fichtner R, McDevitt PW. Rituximab fr the treatment f autimmune hemlytic anemia (AIHA) in adults: an analysis f literature reprts in 92 patients. Bld 2004;104:Abstract Birgens H, Frederiksen H, Hasselbalch HC, et al: A phase III randmized trial cmparing gluccrticid mntherapy versus gluccrticid and rituximab in patients with autimmune haemlytic anaemia. Br J Haematl 2013; 163(3): Schllkpf C, Kjeldsen L, Bjerrum OW, et al: Rituximab in chrnic cld agglutinin disease: a prspective study f 20 patients. Leuk Lymphma 2006; 47(N2): Berentsen S, Ulvestad E, Gjertsen BT, et al: Rituximab fr primary chrnic cld agglutinin disease: a prspective study f 37 curses f therapy in 27 patients. Bld 2004; 103(8): Reynaud Q, Durieu I, Dutertre M, et al. Efficacy and safety f rituximab in aut-immune hemlytic anemia: A meta-analysis f 21 studies. Autimmun Rev. 2015;14(4): Barcellini W, Zaja F, Zaninni A, et al, Lw-dse Rituximab in Adult Patients With Idipathic Autimmune Hemlytic Anemia: Clinical Efficacy and Bilgic Studies, Bld, 2012, 119(16): Rumier M, Lustau V, Guillaud C, et al. Characteristics and utcme f warm autimmune hemlytic anemia in adults: New insights based n a single-center experience with 60 patients. Am J Hematl. 2014;89(9):E150-E Gbert D, Bussel JB, Cunningham-Rundles C, et al. Efficacy and safety f rituximab in cmmn variable immundeficiency-assciated immune cytpenias: a retrspective multicentre study n 33 patients. Br J Haematl. 2011;155(4): First Cast Service Optins, Inc. Lcal Cverage Determinatin (LCD): Rituximab (Rituxan ) (L33746). Centers fr Medicare & Medicaid Services, Inc. Updated n 1/3/2017 with effective date 1/17/2017. Accessed September Cahaba Gvernment Benefit Administratrs, LLC. Lcal Cverage Article fr Drugs and Bilgicals - Chemtherapeutic Agents (A52701). Centers fr Medicare & Medicaid Services, Inc. Updated n 6/15/2017 with effective date 6/22/2017. Accessed September Natinal Gvernment Services, Inc. Lcal Cverage Article: Rituximab (Rituxan ) (effective 2010) - Related t LCD L33394 (A52452). Centers fr Medicare & Medicaid Services, Inc. Updated n 3/17/2017 with effective date f 3/23/2017. Accessed September Mda Health Plan, Inc. Medical Necessity Criteria Page 7/19

8 34. Palmett GBA. Lcal Cverage Determinatin: Rituximab (Rituxan ) (L35026). Centers fr Medicare & Medicaid Services, Inc. Updated n 9/01/2017 with effective date f 10/01/2017. Accessed September Cahaba Gvernment Benefit Administratrs, LLC. Lcal Cverage Determinatin (LCD): Drugs and Bilgicals: Rituximab (Rituxan ) (L34306). Centers fr Medicare & Medicaid Services, Inc. Updated n 6/15/2017 with effective date 6/22/2016. Accessed September Appendix 1 Cvered Diagnsis Cdes ICD-10 ICD-10 Descriptin C79.32 Secndary malignant neplasm f cerebral meninges C81.00 Ndular lymphcyte predminant Hdgkin lymphma, unspecified site C81.01 Ndular lymphcyte predminant Hdgkin lymphma, lymph ndes f head, face, and neck C81.02 Ndular lymphcyte predminant Hdgkin lymphma, intrathracic lymph ndes C81.03 Ndular lymphcyte predminant Hdgkin lymphma, intra-abdminal lymph ndes C81.04 Ndular lymphcyte predminant Hdgkin lymphma, lymph ndes f axilla and upper limb C81.05 Ndular lymphcyte predminant Hdgkin lymphma, lymph ndes f inguinal regin and lwer limb C81.06 Ndular lymphcyte predminant Hdgkin lymphma, intrapelvic lymph ndes C81.07 Ndular lymphcyte predminant Hdgkin lymphma, spleen C81.08 Ndular lymphcyte predminant Hdgkin lymphma, lymph ndes f multiple sites C81.09 Ndular lymphcyte predminant Hdgkin lymphma, extrandal and slid rgan sites C82.00 Fllicular lymphma grade I, unspecified site C82.01 Fllicular lymphma grade I, lymph ndes f head, face and neck C82.02 Fllicular lymphma, grade I, intrathracic lymph ndes C82.03 Fllicular lymphma grade I, intra-abdminal lymph ndes C82.04 Fllicular lymphma grade I, lymph ndes f axilla and upper limb C82.05 Fllicular lymphma grade I, lymph ndes f inguinal reginal and lwer limb C82.06 Fllicular lymphma grade I, intrapelvic lymph ndes C82.07 Fllicular lymphma grade I, spleen C82.08 Fllicular lymphma grade I, lymph ndes f multiple sites C82.09 Fllicular lymphma grade I, extrandal and slid rgan sites C82.10 Fllicular lymphma grade II, unspecified site C82.11 Fllicular lymphma grade II, lymph ndes f head, face and neck C82.12 Fllicular lymphma, grade II, intrathracic lymph ndes C82.13 Fllicular lymphma grade II, intra-abdminal lymph ndes C82.14 Fllicular lymphma grade II, lymph ndes f axilla and upper limb C82.15 Fllicular lymphma grade II, lymph ndes f inguinal regin and lwer limb C82.16 Fllicular lymphma grade II, intrapelvic lymph ndes C82.17 Fllicular lymphma grade II, spleen C82.18 Fllicular lymphma grade II, lymph ndes f multiple sites Mda Health Plan, Inc. Medical Necessity Criteria Page 8/19

9 C82.19 Fllicular lymphma grade II, extrandal and slid rgan sites C82.20 Fllicular lymphma grade III, unspecified, unspecified site C82.21 Fllicular lymphma grade III, unspecified, lymph ndes f head, face and neck C82.22 Fllicular lymphma, grade III, unspecified, intrathracic lymph ndes C82.23 Fllicular lymphma grade III, unspecified, intra-abdminal lymph ndes C82.24 Fllicular lymphma grade III, unspecified, lymph ndes f axilla and upper limb C82.25 Fllicular lymphma grade III, unspecified, lymph ndes f inguinal regin and lwer limb C82.26 Fllicular lymphma grade III, unspecified, intrapelvic lymph ndes C82.27 Fllicular lymphma grade III, unspecified, spleen C82.28 Fllicular lymphma grade III, unspecified, lymph ndes f multiple sites C82.29 Fllicular lymphma grade III, unspecified, extrandal and slid rgan sites C82.30 Fllicular lymphma grade IIIa, unspecified site C82.31 Fllicular lymphma grade IIIa, lymph ndes f head, face and neck C82.32 Fllicular lymphma, grade IIIa, intrathracic lymph ndes C82.33 Fllicular lymphma grade IIIa, intra-abdminal lymph ndes C82.34 Fllicular lymphma grade IIIa, lymph ndes f axilla and upper limb C82.35 Fllicular lymphma grade IIIa, lymph ndes f inguinal regin and lwer limb C82.36 Fllicular lymphma grade IIIa, intrapelvic lymph ndes C82.37 Fllicular lymphma grade IIIa, spleen C82.38 Fllicular lymphma grade IIIa, lymph ndes f multiple sites C82.39 Fllicular lymphma grade IIIa, extrandal and slid rgan sites C82.40 Fllicular lymphma grade IIIb, unspecified site C82.41 Fllicular lymphma grade IIIb, lymph ndes f head, face and neck C82.42 Fllicular lymphma, grade IIIb, intrathracic lymph ndes C82.43 Fllicular lymphma grade IIIb, intra-abdminal lymph ndes C82.44 Fllicular lymphma grade IIIb, lymph ndes f axilla and upper limb C82.45 Fllicular lymphma grade IIIb, lymph ndes f inguinal regin and lwer limb C82.46 Fllicular lymphma grade IIIb, intrapelvic lymph ndes C82.47 Fllicular lymphma grade IIIb, spleen C82.48 Fllicular lymphma grade IIIb, lymph ndes f multiple sites C82.49 Fllicular lymphma grade IIIb, extrandal and slid rgan sites C82.60 Cutaneus fllicle center lymphma, unspecified site C82.61 Cutaneus fllicle center lymphma, lymph ndes f head, face and neck C82.62 Cutaneus fllicle center lymphma, intrathracic lymph ndes C82.63 Cutaneus fllicle center lymphma, intra-abdminal lymph ndes C82.64 Cutaneus fllicle center lymphma, lymph ndes f axilla and upper limb C82.65 Cutaneus fllicle center lymphma, lymph ndes f inguinal regin and lwer limb C82.66 Cutaneus fllicle center lymphma, intrapelvic lymph ndes C82.67 Cutaneus fllicle center lymphma, spleen C82.68 Cutaneus fllicle center lymphma, lymph ndes f multiple sites Mda Health Plan, Inc. Medical Necessity Criteria Page 9/19

10 C82.69 Cutaneus fllicle center lymphma, extrandal and slid rgan sites C82.90 Fllicular lymphma, unspecified, unspecified site C82.91 Fllicular lymphma, unspecified, lymph ndes f head, face and neck C82.92 Fllicular lymphma, unspecified, intrathracic lymph ndes C82.93 Fllicular lymphma, unspecified, intra-abdminal lymph ndes C82.94 Fllicular lymphma, unspecified, lymph ndes f axilla and upper limb C82.95 Fllicular lymphma, unspecified lymph ndes f inguinal regin and lwer limb C82.96 Fllicular lymphma, unspecified, intrapelvic lymph ndes C82.97 Fllicular lymphma, unspecified, spleen C82.98 Fllicular lymphma, unspecified, lymph ndes f multiple sites C82.99 Fllicular lymphma, unspecified, extrandal and slid rgan sites C83.00 Small cell B-cell lymphma, unspecified site C83.01 Small cell B-cell lymphma, lymph ndes f head, face and neck C83.02 Small cell B-cell lymphma, intrathracic lymph ndes C83.03 Small cell B-cell lymphma, intra-abdminal lymph ndes C83.04 Small cell B-cell lymphma, lymph ndes f axilla and upper limb C83.05 Small cell B-cell lymphma, lymph ndes f inguinal regin and lwer limb C83.06 Small cell B-cell lymphma, intrapelvic lymph ndes C83.07 Small cell B-cell lymphma, spleen C83.08 Small cell B-cell lymphma, lymph ndes f multiple sites C83.09 Small cell B-cell lymphma, extrandal and slid rgan sites C83.10 Mantle cell lymphma, unspecified site C83.11 Mantle cell lymphma, lymph ndes f head, face and neck C83.12 Mantle cell lymphma, intrathracic lymph ndes C83.13 Mantle cell lymphma, intra-abdminal lymph ndes C83.14 Mantle cell lymphma, lymph ndes f axilla and upper limb C83.15 Mantle cell lymphma, lymph ndes f inguinal regin and lwer limb C83.16 Mantle cell lymphma, intrapelvic lymph ndes C83.17 Mantle cell lymphma, spleen C83.18 Mantle cell lymphma, lymph ndes f multiple sites C83.19 Mantle cell lymphma, extrandal and slid rgan sites C83.30 Diffuse large B-cell lymphma unspecified site C83.31 Diffuse large B-cell lymphma, lymph ndes f head, face, and neck C83.32 Diffuse large B-cell lymphma intrathracic lymph ndes C83.33 Diffuse large B-cell lymphma intra-abdminal lymph ndes C83.34 Diffuse large B-cell lymphma lymph ndes f axilla and upper limb C83.35 Diffuse large B-cell lymphma, lymph ndes f inguinal regin and lwer limb C83.36 Diffuse large B-cell lymphma intrapelvic lymph ndes C83.37 Diffuse large B-cell lymphma, spleen C83.38 Diffuse large B-cell lymphma lymph ndes f multiple sites Mda Health Plan, Inc. Medical Necessity Criteria Page 10/19

11 C83.39 Diffuse large B-cell lymphma extrandal and slid rgan sites C83.70 Burkitt lymphma, unspecified site C83.71 Burkitt lymphma, lymph ndes f head, face, and neck C83.72 Burkitt lymphma, intrathracic lymph ndes C83.73 Burkitt lymphma, intra-abdminal lymph ndes C83.74 Burkitt lymphma, lymph ndes f axilla and upper limb C83.75 Burkitt lymphma, lymph ndes f inguinal regin and lwer limb C83.76 Burkitt lymphma, intrapelvic lymph ndes C83.77 Burkitt lymphma, spleen C83.78 Burkitt lymphma, lymph ndes f multiple sites C83.79 Burkitt lymphma, extrandal and slid rgan sites C83.80 Other nn-fllicular lymphma, unspecified site C83.81 Other nn-fllicular lymphma, lymph ndes f head, face and neck C83.82 Other nn-fllicular lymphma, intrathracic lymph ndes C83.83 Other nn-fllicular lymphma, intra-abdminal lymph ndes C83.84 Other nn-fllicular lymphma, lymph ndes f axilla and upper limb C83.85 Other nn-fllicular lymphma, lymph ndes f inguinal regin and lwer limb C83.86 Other nn-fllicular lymphma, intrapelvic lymph ndes C83.87 Other nn-fllicular lymphma, spleen C83.88 Other nn-fllicular lymphma, lymph ndes f multiple sites C83.89 Other nn-fllicular lymphma, extrandal and slid rgan sites C85.20 Mediastinal (thymic) large B-cell lymphma, unspecified site C85.21 Mediastinal (thymic) large B-cell lymphma, lymph ndes f head, face and neck C85.22 Mediastinal (thymic) large B-cell lymphma, intrathracic lymph ndes C85.23 Mediastinal (thymic) large B-cell lymphma, intra-abdminal lymph ndes C85.24 Mediastinal (thymic) large B-cell lymphma, lymph ndes f axilla and upper limb C85.25 Mediastinal (thymic) large B-cell lymphma, lymph ndes f inguinal regin and lwer limb C85.26 Mediastinal (thymic) large B-cell lymphma, intrapelvic lymph ndes C85.27 Mediastinal (thymic) large B-cell lymphma, spleen C85.28 Mediastinal (thymic) large B-cell lymphma, lymph ndes f multiple sites C85.29 Mediastinal (thymic) large B-cell lymphma, extrandal and slid rgan sites C85.80 Other specified types f nn-hdgkin lymphma, unspecified site C85.81 Other specified types f nn-hdgkin lymphma, lymph ndes f head, face and neck C85.82 Other specified types f nn-hdgkin lymphma, intrathracic lymph ndes C85.83 Other specified types f nn-hdgkin lymphma, intra-abdminal lymph ndes C85.84 Other specified types f nn-hdgkin lymphma, lymph ndes f axilla and upper limb C85.85 Other specified types f nn-hdgkin lymphma, lymph ndes f inguinal regin f lwer limb C85.86 Other specified types f nn-hdgkin lymphma, intrapelvic lymph ndes C85.87 Other specified types f nn-hdgkin lymphma, spleen C85.88 Other specified types f nn-hdgkin lymphma, lymph ndes f multiple sites Mda Health Plan, Inc. Medical Necessity Criteria Page 11/19

12 C85.89 Other specified types f nn-hdgkin lymphma, extrandal and slid rgan sites C88.0 Waldenström macrglbulinemia C88.4 Extrandal marginal zne B-cell lymphma f mucsa-assciated lymphid tissue (MALT-lymphma) C91.00 Acute lymphblastic leukemia nt having achieved remissin C91.01 Acute lymphblastic leukemia, in remissin C91.02 Acute lymphblastic leukemia, in relapse C91.10 Chrnic lymphcytic leukemia f B-cell type nt having achieved remissin C91.12 Chrnic lymphcytic leukemia f B-cell type in relapse C91.40 Hairy cell leukemia nt having achieved remissin C91.42 Hairy cell leukemia, in relapse D36.0 Benign neplasm f lymph ndes D47.Z1 Pst-transplant lymphprliferative disrder (PTLD) D59.1 Other autimmune hemlytic anemias D69.3 Immune thrmbcytpenic purpura D69.41 Evans Syndrme D69.42 Cngenital and hereditary thrmbcytpenia purpura D69.49 Other primary thrmbcytpenia D Chrnic graft-versus-hst disease L10.0 Pemphigus vulgaris 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 Mda Health Plan, Inc. Medical Necessity Criteria Page 12/19

13 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 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 Mda Health Plan, Inc. Medical Necessity Criteria Page 13/19

14 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 Mda Health Plan, Inc. Medical Necessity Criteria Page 14/19

15 M Rheumatid plyneurpathy with rheumatid arthritis f unspecified wrist M Rheumatid plyneurpathy with rheumatid arthritis f right hand M Rheumatid plyneurpathy with rheumatid arthritis f left hand M Rheumatid plyneurpathy with rheumatid arthritis f unspecified hand M Rheumatid plyneurpathy with rheumatid arthritis f right hip M Rheumatid plyneurpathy with rheumatid arthritis f left hip M Rheumatid plyneurpathy with rheumatid arthritis f unspecified hip M Rheumatid plyneurpathy with rheumatid arthritis f right knee M Rheumatid plyneurpathy with rheumatid arthritis f left knee 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 M05.70 Rheumatid arthritis with rheumatid factr f unspecified site withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f right shulder withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f left shulder withut rgan r systems invlvement Mda Health Plan, Inc. Medical Necessity Criteria Page 15/19

16 M Rheumatid arthritis with rheumatid factr f unspecified shulder withut rgan r systems M Rheumatid arthritis with rheumatid factr f right elbw withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f left elbw withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f unspecified elbw withut rgan r systems M Rheumatid arthritis with rheumatid factr f right wrist withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f left wrist withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f unspecified wrist withut rgan r systems 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 M Rheumatid arthritis with rheumatid factr f unspecified hand withut rgan r systems M Rheumatid arthritis with rheumatid factr f right hip withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f left hip withut rgan r systems invlvement M Rheumatid arthritis with rheumatid factr f unspecified hip withut rgan r systems 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 M Rheumatid arthritis with rheumatid factr f unspecified knee withut rgan r systems M Rheumatid arthritis with rheumatid factr f right ankle and ft withut rgan r systems M Rheumatid arthritis with rheumatid factr f left ankle and ft withut rgan r systems M Rheumatid arthritis with rheumatid factr f unspecified ankle and ft withut rgan r systems M05.79 Rheumatid arthritis with rheumatid factr f multiple sites withut rgan r systems 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 Mda Health Plan, Inc. Medical Necessity Criteria Page 16/19

17 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 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 Mda Health Plan, Inc. Medical Necessity Criteria Page 17/19

18 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 M31.1 Thrmbtic micrangipathy M31.30 Wegener s granulmatsis withut renal invlvement M31.31 Wegener s granulmatsis with renal invlvement M31.7 Micrscpic plyangiitis R59.0 Lcalized enlarged lymph ndes R59.1 Generalized enlarged lymph ndes R59.9 Enlarged lymph ndes, unspecified Z85.71 Persnal histry f Hdgkin lymphma Z85.72 Persnal histry f nn-hdgkin lymphmas Z85.79 Persnal histry f ther malignant neplasms f lymphid, hematpietic and related tissues Appendix 2 Centers fr Medicare and Medicaid Services (CMS) Medicare cverage fr utpatient (Part B) drugs is utlined in the Medicare Benefit Plicy Manual (Pub ), Chapter 15, 50 Drugs and Bilgicals. In additin, Natinal Cverage Determinatin (NCD) and Lcal Cverage Determinatins (LCDs) may exist and cmpliance with these plicies is required where applicable. They can be fund at: Additinal indicatins may be cvered at the discretin f the health plan. Medicare Part B Cvered Diagnsis Cdes (applicable t existing NCD/LCD): Jurisdictin(s): J NCD/LCD Dcument (s): A Mda Health Plan, Inc. Medical Necessity Criteria Page 18/19

19 Jurisdictin(s): 6, K NCD/LCD Dcument (s): A52452 Jurisdictin(s): M NCD/LCD Dcument (s): L35026 Jurisdictin(s): J NCD/LCD Dcument (s): L34306 Jurisdictin(s): N NCD/LCD Dcument (s): L Medicare Part B Administrative Cntractr (MAC) Jurisdictins Jurisdictin Applicable State/US Territry Cntractr E (1) CA, HI, NV, AS, GU, CNMI Nridian Healthcare Slutins, LLC F (2 & 3) AK, WA, OR, ID, ND, SD, MT, WY, UT, AZ Nridian Healthcare Slutins, LLC 5 KS, NE, IA, MO Wiscnsin Physicians Service Insurance Crp (WPS) 6 MN, WI, IL Natinal Gvernment Services, Inc. (NGS) H (4 & 7) LA, AR, MS, TX, OK, CO, NM Nvitas Slutins, Inc. 8 MI, IN Wiscnsin Physicians Service Insurance Crp (WPS) N (9) FL, PR, VI First Cast Service Optins, Inc. J (10) TN, GA, AL Cahaba Gvernment Benefit Administratrs, LLC M (11) NC, SC, WV, VA (excluding belw) Palmett GBA, LLC L (12) DE, MD, PA, NJ, DC (includes Arlingtn & Fairfax cunties and the city f Alexandria in VA) Nvitas Slutins, Inc. K (13 & 14) NY, CT, MA, RI, VT, ME, NH Natinal Gvernment Services, Inc. (NGS) 15 KY, OH CGS Administratrs, LLC Mda Health Plan, Inc. Medical Necessity Criteria Page 19/19