Actemra (tcilizumab) (Intravenus) Last Review Date: 06/01/2018 Date f Origin: 09/21/2010 Dcument Number: MODA-0002 Dates Reviewed: 12/2010, 03/2011, 05/2011, 06/2011, 09/2011, 12/2011, 03/2012, 06/2012, 09/2012, 09/2012, 11/2012, 12/2012, 03/2013, 06/2013, 09/2013, 11/2013, 12/2013, 03/2014, 06/2014, 09/2014, 12/2014, 03/2015, 5/2015, 9/2015, 12/0215, 03/2016, 06/2016, 09/2016, 12/2016, 03/2017, 05/2017, 09/2017, 12/2017, 03/2018, 06/2018 I. Length f Authrizatin Cverage will be prvided as fllws: Castleman s Disease: 4 mnths and may be renewed Cytkine Release Syndrme: 4 dses nly and may nt be renewed Immune Checkpint Inhibitr related arthritis: 1 dse and may nt be renewed All ther indicatins: 6 mnths and may be renewed. II. Dsing Limits A. Quantity Limit (max daily dse) [Pharmacy Benefit]: Actemra 80 mg/4 ml vial: 1 vial per 14 days Actemra 200 mg/10 ml vial: 1 vial per 14 days Actemra 400 mg/20 ml vial: 2 vials per 14 days B. Max Units (per dse and ver time) [Medical Benefit]: Diagnsis Billable Units Interval (days) Rheumatid Arthritis & Plyarticular Juvenile Idipathic Arthritis 800 28 Systemic Juvenile Idipathic Arthritis & Castleman s Disease (NHL) 800 14 Cytkine Release Syndrme (CRS) 3200 1 curse f therapy nly Immune Checkpint Inhibitr related arthritis 800 1 curse f therapy nly III. Initial Apprval Criteria Site f care specialty infusin prgram requirements are met (refer t Mda Site f Care Plicy). Self-administered injectable medicatins are nt cvered when supplied in a prvider s ffice, clinic r facility. Cverage is prvided in the fllwing cnditins: Mda Health Plan, Inc. Medical Necessity Criteria Page 1/18
Patient has been evaluated and screened fr the presence f latent TB infectin prir t initiating treatment; AND Patient des nt have an active infectin, including clinically imprtant lcalized infectins; AND Must nt be administered cncurrently with live vaccines; AND Patient is nt n cncurrent treatment with anther TNF-inhibitr, bilgic respnse mdifier r ther nn-bilgic agent (i.e., apremilast); AND Rheumatid Arthritis Patient is 18 years r lder; AND Physician has assessed baseline disease severity utilizing an bjective measure/tl; AND Dcumented mderate t severe active disease; AND Patient has had at least a 3 mnth trial and failed previus therapy with ONE ral disease mdifying anti-rheumatic agent (DMARD) such as methtrexate, azathiprine, auranfin, hydrxychlrquine, penicillamine, sulfasalazine, leflunmide ; AND May be used alne r in cmbinatin with methtrexate; AND Patient must try and have an inadequate respnse, cntraindicatin, r intlerance t at least a three (3) mnth trial f Enbrel AND Humira; OR Patient is cntinuing treatment Juvenile Idipathic Arthritis (JIA) Patient is 2 years r lder ; AND Patient has active systemic (SJIA) r plyarticular (PJIA) disease; AND Physician has assessed baseline disease severity utilizing an bjective measure/tl; AND Patient has had at least a 1-mnth trial and failure (unless cntraindicated r intlerant) f previus therapy with either ral nn-steridal anti-inflammatry drugs (NSAIDs) OR a systemic gluccrticid (prednisne, methylprednislne, etc.); AND May be used alne r in cmbinatin with methtrexate; AND (Nte: The fllwing applies t plyarticular (PJIA) disease nly) Patient must try and have an inadequate respnse, cntraindicatin, r intlerance t at least a three (3) mnth trial f Enbrel AND Humira; OR Patient is cntinuing treatment Castleman s Disease (NHL) Used as a single agent; AND Patient has unicentric disease; AND Patient is human immundeficiency virus (HIV)-negative and human herpesvirus-8 (HHV-8)-negative; AND Used as secnd-line therapy fr relapsed r refractry disease; OR Patient has multicentric disease; AND Mda Health Plan, Inc. Medical Necessity Criteria Page 2/18
Used as subsequent therapy fr relapsed, refractry, r prgressive disease Cytkine Release Syndrme (CRS) Patient is 2 years r lder; AND Patient has received r will be receiving chimeric antigen receptr (CAR) T cell therapy; AND Tcilizumab is being rdered t have n-hand, prir t the administratin f CAR-T therapy, if needed fr the treatment f CRS; OR Patient has a cnfirmed diagnsis f CAR-T therapy induced severe r life-threatening CRS Management f Immune Checkpint Inhibitr related Inflammatry Arthritis Patient has been receiving therapy with an immune checkpint inhibitr (e.g. nivlumab, pembrlizumab, atezlizumab, avelumab, durvalumab, etc.); AND Patient has inflammatry arthritis related t their immuntherapy; AND Dcumented severe disease; AND Patient s cnditin is refractry t crticsterids and anti-inflammatry agents FDA Apprved 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: neutrpenia (abslute neutrphil cunt (ANC) belw 1000 per mm 3 ), thrmbcytpenia (platelet cunt belw 100,000 per mm 3 ), hepattxicity (ALT r AST abve 3-5 times the upper limit f nrmal), gastrintestinal perfratin, severe hypersensitivity reactins, etc.; AND Patient is receiving nging mnitring fr presence f TB r ther active infectins; AND (Onclgy Indicatins) Castleman s Disease (NHL) Tumr respnse with stabilizatin f disease r decrease in size f tumr r tumr spread (Nn-Onclgy Indicatins) Rheumatid arthritis (RA) Disease respnse as indicated by imprvement in signs and symptms cmpared t baseline such as the number f tender and swllen jint cunts and/r an imprvement n a disease activity scring tl [e.g. an imprvement n a cmpsite scring index such as Disease Activity Scre-28 (DAS28) f 1.2 pints r mre r a 20% imprvement n the American Cllege f Rheumatlgy-20 (ACR20) criteria] Juvenile Idipathic Arthritis (SJIA/PJIA) Disease respnse as indicated by imprvement in signs and symptms cmpared t baseline such as the number f tender and swllen jint cunts and/r an imprvement n a disease Mda Health Plan, Inc. Medical Necessity Criteria Page 3/18
activity scring tl [e.g. an imprvement n a cmpsite scring index such as Juvenile Arthritis Disease Activity Scre (JADAS) r the American Cllege f Rheumatlgy (ACR) Pediatric (ACR-Pedi 30) f at least 30% imprvement frm baseline in three f six variables]. Cytkine Release Syndrme May nt be renewed Management f Immune Checkpint Inhibitr related Inflammatry Arthritis May nt be renewed V. Dsage/Administratin Dses exceeding 800 mg per infusin are nt recmmended Indicatin Adult Rheumatid Arthritis Plyarticular Juvenile Idipathic Arthritis Systemic Juvenile Idipathic Arthritis Castleman s Disease (NHL) Cytkine Release Syndrme (CRS) Immune- Checkpint Inhibitr related inflammatry arthritis 4 mg/kg IV every 4 weeks Dse May increase t 8 mg/kg every 4 weeks based n clinical respnse Weight 30 kg 8 mg/kg IV every 4 weeks Weight < 30 kg 10 mg/kg IV every 4 weeks Weight 30 kg 8 mg/kg IV every 2 weeks Weight < 30 kg 12 mg/kg IV every 2 weeks 8 mg/kg IV every 2 weeks fr 16 weeks (8 dses) Weight 30 kg 8 mg/kg IV every 8 hurs, if needed, up t a maximum f 4 ttal dses* Weight < 30 kg 12 mg/kg IV every 8 hurs, if needed, up t a maximum f 4 ttal dses* *If n clinical imprvement in the signs and symptms f CRS ccurs after the first dse, up t 3 additinal dses may be administered. The interval between cnsecutive dses shuld be at least 8 hurs. May be used with r withut crticsterids. 4 mg/kg IV nce VI. Billing Cde/Availability Infrmatin Jcde: J3262 Injectin, tcilizumab, 1 mg; 1 billable unit = 1 mg NDC: Actemra 80 mg/ 4 ml vial: 50242-0135-xx Mda Health Plan, Inc. Medical Necessity Criteria Page 4/18
Actemra 200 mg/10 ml vial: 50242-0136-xx Actemra 400 mg/20 ml vial:50242-0137-xx VII. References 1. Actemra [package insert]. Suth San Francisc, CA; Genentech, Inc; March 2018. Accessed May 2018. 2. Referenced with permissin frm the NCCN Drugs & Bilgics Cmpendium (NCCN Cmpendium ) tcilizumab. Natinal Cmprehensive Cancer Netwrk, 2018. 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 May 2018. 3. Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American Cllege f Rheumatlgy Guideline fr the Treatment f Rheumatid Arthritis. Arthritis Care Res (Hbken). 2015 Nv 6. di: 10.1002/acr.22783. 4. Beukelman T, Patkar NM, Saag KG, et al. 2011 American Cllege f Rheumatlgy recmmendatins fr the treatment f juvenile idipathic arthritis: initiatin and safety mnitring f therapeutic agents fr the treatment f arthritis and systemic features. Arthritis Care Res (Hbken). 2011 Apr;63(4):465-82. 5. Ringld S, Weiss PF, Beukelman T, et al. 2013 update f the 2011 American Cllege f Rheumatlgy recmmendatins fr the treatment f juvenile idipathic arthritis: recmmendatins fr the medical therapy f children with systemic juvenile idipathic arthritis and tuberculsis screening amng children receiving bilgic medicatins. Arthritis Rheum. 2013 Oct;65(10):2499-512. 6. DeWitt EM, Kimura Y, Beukelman T, et al. Cnsensus treatment plans fr new-nset systemic juvenile idipathic arthritis. Arthritis Care Res (Hbken). 2012 Jul;64(7):1001-10. 7. Nishimt N, Kanakura Y, Azasa K, et al. Humanized anti-interleukin-6 receptr antibdy treatment f multicentric Castleman disease. Bld 2005;106:2627-2632 8. 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. 2017 Mar 6. pii: annrheumdis-2016-210715. 9. Fraser JA, Weyand CM, Newman NJ, Biusse V. The treatment f giant cell arteritis. Rev Neurl Dis. 2008 Summer;5(3):140-52. 10. Dasgupta B, Brg FA, Hassan N, et al. BSR and BHPR guidelines fr the management f giant cell arteritis. Rheumatlgy (Oxfrd). 2010 Aug;49(8):1594-7. 11. Natinal Institute fr Health and Care Excellence. NICE 2009. Rheumatid Arthritis in Adults: Management. Published 25 February 2009. Clinical Guideline [CG79]. https://www.nice.rg.uk/guidance/cg79/resurces/rheumatid-arthritis-in-adultsmanagement-pdf-975636823525. 12. Natinal Institute fr Health and Care Excellence. NICE 2010. Adalimumab, etanercept, infliximab, rituximab and abatacept fr the treatment f rheumatid arthritis after failure f a TNF inhibitr. Published 10 Octber 2012. Clinical Guideline [TA195]. Mda Health Plan, Inc. Medical Necessity Criteria Page 5/18
https://www.nice.rg.uk/guidance/ta195/resurces/adalimumab-etanercept-infliximabrituximab-and-abatacept-fr-the-treatment-f-rheumatid-arthritis-after-the-failure-f-a- tnf-inhibitr-pdf-82598558287813. 13. Ward MM, Guthri LC, Alba MI. Rheumatid Arthritis Respnse Criteria And Patient- Reprted Imprvement in Arthritis Activity: Is an ACR20 Respnse Meaningful t Patients. Arthritis Rheumatl. 2014 Sep; 66(9): 2339 2343. di: 10.1002/art.38705 14. Ringld S, Bittner R, Neggi T, et al. Perfrmance f rheumatid arthritis disease activity measures and juvenile arthritis disease activity scres in plyarticular-curse juvenile idipathic arthritis: Analysis f their ability t classify the American Cllege f Rheumatlgy pediatric measures f respnse and the preliminary criteria fr flare and inactive disease. Arthritis Care Res (Hbken). 2010 Aug;62(8):1095-102. 15. Cnslar A, Giancane G, Schiappapietra B, et al. Clinical utcme measures in juvenile idipathic arthritis. Pediatric Rheumatlgy 18 April 2016 14:23. 16. Strud C, Hedge A, Cherry C, et al. Tciluzumab fr the management f immune mediated adverse events secndary t PD-1 blckage. Jurnal f Onclgy Pharmacy Practice. 2017 December. https://di.rg/10.1177/1078155217745144. Appendix 1 Cvered Diagnsis Cdes ICD-10 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 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 Mda Health Plan, Inc. Medical Necessity Criteria Page 6/18
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 C82.50 Diffuse fllicle center lymphma, unspecified site C82.51 Diffuse fllicle center lymphma, lymph ndes f head, face and neck C82.52 Diffuse fllicle center lymphma, intrathracic lymph ndes C82.53 Diffuse fllicle center lymphma, intra-abdminal lymph ndes C82.54 Diffuse fllicle center lymphma, lymph ndes f axilla and upper limb C82.55 Diffuse fllicle center lymphma, lymph ndes f inguinal regin and lwer limb C82.56 Diffuse fllicle center lymphma, intrapelvic lymph ndes C82.57 Diffuse fllicle center lymphma, spleen C82.58 Diffuse fllicle center lymphma, lymph ndes f multiple sites C82.59 Diffuse fllicle center lymphma, 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 Mda Health Plan, Inc. Medical Necessity Criteria Page 7/18
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 C82.69 Cutaneus fllicle center lymphma, extrandal and slid rgan sites C82.80 Other types f fllicular lymphma, unspecified site C82.81 Other types f fllicular lymphma, lymph ndes f head, face and neck C82.82 Other types f fllicular lymphma, intrathracic lymph ndes C82.83 Other types f fllicular lymphma, intra-abdminal lymph ndes C82.84 Other types f fllicular lymphma, lymph ndes f axilla and upper limb C82.85 Other types f fllicular lymphma, lymph ndes f inguinal regin and lwer limb C82.86 Other types f fllicular lymphma, intrapelvic lymph ndes C82.87 Other types f fllicular lymphma, spleen C82.88 Other types f fllicular lymphma, lymph ndes f multiple sites C82.89 Other types f fllicular 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 C83.30 Diffuse large B-cell lymphma unspecified site C83.31 Diffuse large B-cell lymphma, lymph ndes f head, face, and neck Mda Health Plan, Inc. Medical Necessity Criteria Page 8/18
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 C83.39 Diffuse large B-cell lymphma extrandal and slid rgan sites C91.00 Acute lymphblastic leukemia nt having achieved remissin C91.01 Acute lymphblastic leukemia, in remissin C91.02 Acute lymphblastic leukemia, in relapse D36.0 Benign neplasm f lymph ndes D47.Z2 Castleman disease M05.10 Rheumatid lung disease with rheumatid arthritis f unspecified site M05.111 Rheumatid lung disease with rheumatid arthritis f right shulder M05.112 Rheumatid lung disease with rheumatid arthritis f left shulder M05.119 Rheumatid lung disease with rheumatid arthritis f unspecified shulder M05.121 Rheumatid lung disease with rheumatid arthritis f right elbw M05.122 Rheumatid lung disease with rheumatid arthritis f left elbw M05.129 Rheumatid lung disease with rheumatid arthritis f unspecified elbw M05.131 Rheumatid lung disease with rheumatid arthritis f right wrist M05.132 Rheumatid lung disease with rheumatid arthritis f left wrist M05.139 Rheumatid lung disease with rheumatid arthritis f unspecified wrist M05.141 Rheumatid lung disease with rheumatid arthritis f right hand M05.142 Rheumatid lung disease with rheumatid arthritis f left hand M05.149 Rheumatid lung disease with rheumatid arthritis f unspecified hand M05.151 Rheumatid lung disease with rheumatid arthritis f right hip M05.152 Rheumatid lung disease with rheumatid arthritis f left hip M05.159 Rheumatid lung disease with rheumatid arthritis f unspecified hip M05.161 Rheumatid lung disease with rheumatid arthritis f right knee M05.162 Rheumatid lung disease with rheumatid arthritis f left knee M05.169 Rheumatid lung disease with rheumatid arthritis f unspecified knee M05.171 Rheumatid lung disease with rheumatid arthritis f right ankle and ft M05.172 Rheumatid lung disease with rheumatid arthritis f left ankle and ft M05.179 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 M05.211 Rheumatid vasculitis with rheumatid arthritis f right shulder M05.212 Rheumatid vasculitis with rheumatid arthritis f left shulder M05.219 Rheumatid vasculitis with rheumatid arthritis f unspecified shulder Mda Health Plan, Inc. Medical Necessity Criteria Page 9/18
M05.221 Rheumatid vasculitis with rheumatid arthritis f right elbw M05.222 Rheumatid vasculitis with rheumatid arthritis f left elbw M05.229 Rheumatid vasculitis with rheumatid arthritis f unspecified elbw M05.231 Rheumatid vasculitis with rheumatid arthritis f right wrist M05.232 Rheumatid vasculitis with rheumatid arthritis f left wrist M05.239 Rheumatid vasculitis with rheumatid arthritis f unspecified wrist M05.241 Rheumatid vasculitis with rheumatid arthritis f right hand M05.242 Rheumatid vasculitis with rheumatid arthritis f left hand M05.249 Rheumatid vasculitis with rheumatid arthritis f unspecified hand M05.251 Rheumatid vasculitis with rheumatid arthritis f right hip M05.252 Rheumatid vasculitis with rheumatid arthritis f left hip M05.259 Rheumatid vasculitis with rheumatid arthritis f unspecified hip M05.261 Rheumatid vasculitis with rheumatid arthritis f right knee M05.262 Rheumatid vasculitis with rheumatid arthritis f left knee M05.269 Rheumatid vasculitis with rheumatid arthritis f unspecified knee M05.271 Rheumatid vasculitis with rheumatid arthritis f right ankle and ft M05.272 Rheumatid vasculitis with rheumatid arthritis f left ankle and ft M05.279 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 M05.311 Rheumatid heart disease with rheumatid arthritis f right shulder M05.312 Rheumatid heart disease with rheumatid arthritis f left shulder M05.319 Rheumatid heart disease with rheumatid arthritis f unspecified shulder M05.321 Rheumatid heart disease with rheumatid arthritis f right elbw M05.322 Rheumatid heart disease with rheumatid arthritis f left elbw M05.329 Rheumatid heart disease with rheumatid arthritis f unspecified elbw M05.331 Rheumatid heart disease with rheumatid arthritis f right wrist M05.332 Rheumatid heart disease with rheumatid arthritis f left wrist M05.339 Rheumatid heart disease with rheumatid arthritis f unspecified wrist M05.341 Rheumatid heart disease with rheumatid arthritis f right hand M05.342 Rheumatid heart disease with rheumatid arthritis f left hand M05.349 Rheumatid heart disease with rheumatid arthritis f unspecified hand M05.351 Rheumatid heart disease with rheumatid arthritis f right hip M05.352 Rheumatid heart disease with rheumatid arthritis f left hip M05.359 Rheumatid heart disease with rheumatid arthritis f unspecified hip M05.361 Rheumatid heart disease with rheumatid arthritis f right knee M05.362 Rheumatid heart disease with rheumatid arthritis f left knee M05.369 Rheumatid heart disease with rheumatid arthritis f unspecified knee M05.371 Rheumatid heart disease with rheumatid arthritis f right ankle and ft M05.372 Rheumatid heart disease with rheumatid arthritis f left ankle and ft Mda Health Plan, Inc. Medical Necessity Criteria Page 10/18
M05.379 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 M05.411 Rheumatid mypathy with rheumatid arthritis f right shulder M05.412 Rheumatid mypathy with rheumatid arthritis f left shulder M05.419 Rheumatid mypathy with rheumatid arthritis f unspecified shulder M05.421 Rheumatid mypathy with rheumatid arthritis f right elbw M05.422 Rheumatid mypathy with rheumatid arthritis f left elbw M05.429 Rheumatid mypathy with rheumatid arthritis f unspecified elbw M05.431 Rheumatid mypathy with rheumatid arthritis f right wrist M05.432 Rheumatid mypathy with rheumatid arthritis f left wrist M05.439 Rheumatid mypathy with rheumatid arthritis f unspecified wrist M05.441 Rheumatid mypathy with rheumatid arthritis f right hand M05.442 Rheumatid mypathy with rheumatid arthritis f left hand M05.449 Rheumatid mypathy with rheumatid arthritis f unspecified hand M05.451 Rheumatid mypathy with rheumatid arthritis f right hip M05.452 Rheumatid mypathy with rheumatid arthritis f left hip M05.459 Rheumatid mypathy with rheumatid arthritis f unspecified hip M05.461 Rheumatid mypathy with rheumatid arthritis f right knee M05.462 Rheumatid mypathy with rheumatid arthritis f left knee M05.469 Rheumatid mypathy with rheumatid arthritis f unspecified knee M05.471 Rheumatid mypathy with rheumatid arthritis f right ankle and ft M05.472 Rheumatid mypathy with rheumatid arthritis f left ankle and ft M05.479 Rheumatid mypathy with rheumatid arthritis f unspecified ankle and ft M05.49 Rheumatid mypathy with rheumatid arthritis f multiple sites M05.50 Rheumatid mypathy with rheumatid arthritis f unspecified sites M05.511 Rheumatid plyneurpathy with rheumatid arthritis f right shulder M05.512 Rheumatid plyneurpathy with rheumatid arthritis f left shulder M05.519 Rheumatid plyneurpathy with rheumatid arthritis f unspecified shulder M05.521 Rheumatid plyneurpathy with rheumatid arthritis f right elbw M05.522 Rheumatid plyneurpathy with rheumatid arthritis f left elbw M05.529 Rheumatid plyneurpathy with rheumatid arthritis f unspecified elbw M05.531 Rheumatid plyneurpathy with rheumatid arthritis f right wrist M05.532 Rheumatid plyneurpathy with rheumatid arthritis f left wrist M05.539 Rheumatid plyneurpathy with rheumatid arthritis f unspecified wrist M05.541 Rheumatid plyneurpathy with rheumatid arthritis f right hand M05.542 Rheumatid plyneurpathy with rheumatid arthritis f left hand M05.549 Rheumatid plyneurpathy with rheumatid arthritis f unspecified hand M05.551 Rheumatid plyneurpathy with rheumatid arthritis f right hip M05.552 Rheumatid plyneurpathy with rheumatid arthritis f left hip Mda Health Plan, Inc. Medical Necessity Criteria Page 11/18
M05.559 Rheumatid plyneurpathy with rheumatid arthritis f unspecified hip M05.561 Rheumatid plyneurpathy with rheumatid arthritis f right knee M05.562 Rheumatid plyneurpathy with rheumatid arthritis f left knee M05.569 Rheumatid plyneurpathy with rheumatid arthritis f unspecified knee M05.571 Rheumatid plyneurpathy with rheumatid arthritis f right ankle and ft M05.572 Rheumatid plyneurpathy with rheumatid arthritis f left ankle and ft M05.579 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 M05.611 Rheumatid arthritis f right shulder with invlvement f ther rgans and systems M05.612 Rheumatid arthritis f left shulder with invlvement f ther rgans and systems M05.619 Rheumatid arthritis f unspecified shulder with invlvement f ther rgans and systems M05.621 Rheumatid arthritis f right elbw with invlvement f ther rgans and systems M05.622 Rheumatid arthritis f left elbw with invlvement f ther rgans and systems M05.629 Rheumatid arthritis f unspecified elbw with invlvement f ther rgans and systems M05.631 Rheumatid arthritis f right wrist with invlvement f ther rgans and systems M05.632 Rheumatid arthritis f left wrist with invlvement f ther rgans and systems M05.639 Rheumatid arthritis f unspecified wrist with invlvement f ther rgans and systems M05.641 Rheumatid arthritis f right hand with invlvement f ther rgans and systems M05.642 Rheumatid arthritis f left hand with invlvement f ther rgans and systems M05.649 Rheumatid arthritis f unspecified hand with invlvement f ther rgans and systems M05.651 Rheumatid arthritis f right hip with invlvement f ther rgans and systems M05.652 Rheumatid arthritis f left hip with invlvement f ther rgans and systems M05.659 Rheumatid arthritis f unspecified hip with invlvement f ther rgans and systems M05.661 Rheumatid arthritis f right knee with invlvement f ther rgans and systems M05.662 Rheumatid arthritis f left knee with invlvement f ther rgans and systems M05.669 Rheumatid arthritis f unspecified knee with invlvement f ther rgans and systems M05.671 Rheumatid arthritis f right ankle and ft with invlvement f ther rgans and systems M05.672 Rheumatid arthritis f left ankle and ft with invlvement f ther rgans and systems M05.679 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 M05.711 Rheumatid arthritis with rheumatid factr f right shulder withut rgan r systems M05.712 Rheumatid arthritis with rheumatid factr f left shulder withut rgan r systems invlvement M05.719 Rheumatid arthritis with rheumatid factr f unspecified shulder withut rgan r systems M05.721 Rheumatid arthritis with rheumatid factr f right elbw withut rgan r systems invlvement M05.722 Rheumatid arthritis with rheumatid factr f left elbw withut rgan r systems invlvement M05.729 Rheumatid arthritis with rheumatid factr f unspecified elbw withut rgan r systems M05.731 Rheumatid arthritis with rheumatid factr f right wrist withut rgan r systems invlvement M05.732 Rheumatid arthritis with rheumatid factr f left wrist withut rgan r systems invlvement Mda Health Plan, Inc. Medical Necessity Criteria Page 12/18
M05.739 Rheumatid arthritis with rheumatid factr f unspecified wrist withut rgan r systems M05.741 Rheumatid arthritis with rheumatid factr f right hand withut rgan r systems invlvement M05.742 Rheumatid arthritis with rheumatid factr f left hand withut rgan r systems invlvement M05.749 Rheumatid arthritis with rheumatid factr f unspecified hand withut rgan r systems M05.751 Rheumatid arthritis with rheumatid factr f right hip withut rgan r systems invlvement M05.752 Rheumatid arthritis with rheumatid factr f left hip withut rgan r systems invlvement M05.759 Rheumatid arthritis with rheumatid factr f unspecified hip withut rgan r systems M05.761 Rheumatid arthritis with rheumatid factr f right knee withut rgan r systems invlvement M05.762 Rheumatid arthritis with rheumatid factr f left knee withut rgan r systems invlvement M05.769 Rheumatid arthritis with rheumatid factr f unspecified knee withut rgan r systems M05.771 Rheumatid arthritis with rheumatid factr f right ankle and ft withut rgan r systems M05.772 Rheumatid arthritis with rheumatid factr f left ankle and ft withut rgan r systems M05.779 Rheumatid arthritis with rheumatid factr f unspecified ankle and wrist withut rgan r M05.79 Rheumatid arthritis with rheumatid factr f multiple sites withut rgan r systems M05.80 Other rheumatid arthritis with rheumatid factr f unspecified site M05.811 Other rheumatid arthritis with rheumatid factr f right shulder M05.812 Other rheumatid arthritis with rheumatid factr f left shulder M05.819 Other rheumatid arthritis with rheumatid factr f unspecified shulder M05.821 Other rheumatid arthritis with rheumatid factr f right elbw M05.822 Other rheumatid arthritis with rheumatid factr f left elbw M05.829 Other rheumatid arthritis with rheumatid factr f unspecified elbw M05.831 Other rheumatid arthritis with rheumatid factr f right wrist M05.832 Other rheumatid arthritis with rheumatid factr f left wrist M05.839 Other rheumatid arthritis with rheumatid factr f unspecified wrist M05.841 Other rheumatid arthritis with rheumatid factr f right hand M05.842 Other rheumatid arthritis with rheumatid factr f left hand M05.849 Other rheumatid arthritis with rheumatid factr f unspecified hand M05.851 Other rheumatid arthritis with rheumatid factr f right hip M05.852 Other rheumatid arthritis with rheumatid factr f left hip M05.859 Other rheumatid arthritis with rheumatid factr f unspecified hip M05.861 Other rheumatid arthritis with rheumatid factr f right knee M05.862 Other rheumatid arthritis with rheumatid factr f left knee M05.869 Other rheumatid arthritis with rheumatid factr f unspecified knee M05.871 Other rheumatid arthritis with rheumatid factr f right ankle and ft M05.872 Other rheumatid arthritis with rheumatid factr f left ankle and ft M05.879 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 M06.019 Rheumatid arthritis withut rheumatid factr, unspecified shulder Mda Health Plan, Inc. Medical Necessity Criteria Page 13/18
M06.021 Rheumatid arthritis withut rheumatid factr, right elbw M06.022 Rheumatid arthritis withut rheumatid factr, left elbw M06.029 Rheumatid arthritis withut rheumatid factr, unspecified elbw M06.031 Rheumatid arthritis withut rheumatid factr, right wrist M06.032 Rheumatid arthritis withut rheumatid factr, left wrist M06.039 Rheumatid arthritis withut rheumatid factr, unspecified wrist M06.041 Rheumatid arthritis withut rheumatid factr, right hand M06.042 Rheumatid arthritis withut rheumatid factr, left hand M06.049 Rheumatid arthritis withut rheumatid factr, unspecified hand M06.051 Rheumatid arthritis withut rheumatid factr, right hip M06.052 Rheumatid arthritis withut rheumatid factr, left hip M06.059 Rheumatid arthritis withut rheumatid factr, unspecified hip M06.061 Rheumatid arthritis withut rheumatid factr, right knee M06.062 Rheumatid arthritis withut rheumatid factr, left knee M06.069 Rheumatid arthritis withut rheumatid factr, unspecified knee M06.071 Rheumatid arthritis withut rheumatid factr, right ankle and ft M06.072 Rheumatid arthritis withut rheumatid factr, left ankle and ft M06.079 Rheumatid arthritis withut rheumatid factr, unspecified ankle and ft M06.4 Inflammatry plyarthrpathy 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 M06.811 Other specified rheumatid arthritis, right shulder M06.812 Other specified rheumatid arthritis, left shulder M06.819 Other specified rheumatid arthritis, unspecified shulder M06.821 Other specified rheumatid arthritis, right elbw M06.822 Other specified rheumatid arthritis, left elbw M06.829 Other specified rheumatid arthritis, unspecified elbw M06.831 Other specified rheumatid arthritis, right wrist M06.832 Other specified rheumatid arthritis, left wrist M06.839 Other specified rheumatid arthritis, unspecified wrist M06.841 Other specified rheumatid arthritis, right hand M06.842 Other specified rheumatid arthritis, left hand M06.849 Other specified rheumatid arthritis, unspecified hand M06.851 Other specified rheumatid arthritis, right hip M06.852 Other specified rheumatid arthritis, left hip M06.859 Other specified rheumatid arthritis, unspecified hip M06.861 Other specified rheumatid arthritis, right knee M06.862 Other specified rheumatid arthritis, left knee M06.869 Other specified rheumatid arthritis, unspecified knee Mda Health Plan, Inc. Medical Necessity Criteria Page 14/18
M06.871 Other specified rheumatid arthritis, right ankle and ft M06.872 Other specified rheumatid arthritis, left ankle and ft M06.879 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 M08.00 Unspecified juvenile rheumatid arthritis f unspecified site M08.011 Unspecified juvenile rheumatid arthritis, right shulder M08.012 Unspecified juvenile rheumatid arthritis, left shulder M08.019 Unspecified juvenile rheumatid arthritis, unspecified shulder M08.021 Unspecified juvenile rheumatid arthritis, right elbw M08.022 Unspecified juvenile rheumatid arthritis, left elbw M08.029 Unspecified juvenile rheumatid arthritis, unspecified elbw M08.031 Unspecified juvenile rheumatid arthritis, right wrist M08.032 Unspecified juvenile rheumatid arthritis, left wrist M08.039 Unspecified juvenile rheumatid arthritis, unspecified wrist M08.041 Unspecified juvenile rheumatid arthritis, right hand M08.042 Unspecified juvenile rheumatid arthritis, left hand M08.049 Unspecified juvenile rheumatid arthritis, unspecified hand M08.051 Unspecified juvenile rheumatid arthritis, right hip M08.052 Unspecified juvenile rheumatid arthritis, left hip M08.059 Unspecified juvenile rheumatid arthritis, unspecified hip M08.061 Unspecified juvenile rheumatid arthritis, right knee M08.062 Unspecified juvenile rheumatid arthritis, left knee M08.069 Unspecified juvenile rheumatid arthritis, unspecified knee M08.071 Unspecified juvenile rheumatid arthritis, right ankle and ft M08.072 Unspecified juvenile rheumatid arthritis, left ankle and ft M08.079 Unspecified juvenile rheumatid arthritis, unspecified ankle and ft M08.08 Unspecified juvenile rheumatid arthritis, vertebrae M08.09 Unspecified juvenile rheumatid arthritis, multiple sites M08.20 Juvenile rheumatid arthritis with systemic nset, unspecified site M08.211 Juvenile rheumatid arthritis with systemic nset, right shulder M08.212 Juvenile rheumatid arthritis with systemic nset, left shulder M08.219 Juvenile rheumatid arthritis with systemic nset, unspecified shulder M08.221 Juvenile rheumatid arthritis with systemic nset, right elbw M08.222 Juvenile rheumatid arthritis with systemic nset, left elbw M08.229 Juvenile rheumatid arthritis with systemic nset, unspecified elbw M08.231 Juvenile rheumatid arthritis with systemic nset, right wrist M08.232 Juvenile rheumatid arthritis with systemic nset, left wrist M08.239 Juvenile rheumatid arthritis with systemic nset, unspecified wrist Mda Health Plan, Inc. Medical Necessity Criteria Page 15/18
M08.241 Juvenile rheumatid arthritis with systemic nset, right hand M08.242 Juvenile rheumatid arthritis with systemic nset, left hand M08.249 Juvenile rheumatid arthritis with systemic nset, unspecified hand M08.251 Juvenile rheumatid arthritis with systemic nset, right hip M08.252 Juvenile rheumatid arthritis with systemic nset, left hip M08.259 Juvenile rheumatid arthritis with systemic nset, unspecified hip M08.261 Juvenile rheumatid arthritis with systemic nset, right knee M08.262 Juvenile rheumatid arthritis with systemic nset, left knee M08.269 Juvenile rheumatid arthritis with systemic nset, unspecified knee M08.271 Juvenile rheumatid arthritis with systemic nset, right ankle and ft M08.272 Juvenile rheumatid arthritis with systemic nset, left ankle and ft M08.279 Juvenile rheumatid arthritis with systemic nset, unspecified ankle and ft M08.28 Juvenile rheumatid arthritis with systemic nset, vertebrae M08.29 Juvenile rheumatid arthritis with systemic nset, multiple sites M08.3 Juvenile rheumatid plyarthritis (sernegative) M08.40 Pauciarticular juvenile rheumatid arthritis, unspecified site M08.411 Pauciarticular juvenile rheumatid arthritis, right shulder M08.412 Pauciarticular juvenile rheumatid arthritis, left shulder M08.419 Pauciarticular juvenile rheumatid arthritis, unspecified shulder M08.421 Pauciarticular juvenile rheumatid arthritis, right elbw M08.422 Pauciarticular juvenile rheumatid arthritis, left elbw M08.429 Pauciarticular juvenile rheumatid arthritis, unspecified elbw M08.431 Pauciarticular juvenile rheumatid arthritis, right wrist M08.432 Pauciarticular juvenile rheumatid arthritis, left wrist M08.439 Pauciarticular juvenile rheumatid arthritis, unspecified wrist M08.441 Pauciarticular juvenile rheumatid arthritis, right hand M08.442 Pauciarticular juvenile rheumatid arthritis, left hand M08.449 Pauciarticular juvenile rheumatid arthritis, unspecified hand M08.451 Pauciarticular juvenile rheumatid arthritis, right hip M08.452 Pauciarticular juvenile rheumatid arthritis, left hip M08.459 Pauciarticular juvenile rheumatid arthritis, unspecified hip M08.461 Pauciarticular juvenile rheumatid arthritis, right knee M08.462 Pauciarticular juvenile rheumatid arthritis, left knee M08.469 Pauciarticular juvenile rheumatid arthritis, unspecified knee M08.471 Pauciarticular juvenile rheumatid arthritis, right ankle and ft M08.472 Pauciarticular juvenile rheumatid arthritis, left ankle and ft M08.479 Pauciarticular juvenile rheumatid arthritis, unspecified ankle and ft M08.48 Pauciarticular juvenile rheumatid arthritis, vertebrae M08.80 Other juvenile arthritis, unspecified site M08.811 Other juvenile arthritis, right shulder Mda Health Plan, Inc. Medical Necessity Criteria Page 16/18
M08.812 Other juvenile arthritis, left shulder M08.819 Other juvenile arthritis, unspecified shulder M08.821 Other juvenile arthritis, right elbw M08.822 Other juvenile arthritis, left elbw M08.829 Other juvenile arthritis, unspecified elbw M08.831 Other juvenile arthritis, right wrist M08.832 Other juvenile arthritis, left wrist M08.839 Other juvenile arthritis, unspecified wrist M08.841 Other juvenile arthritis, right hand M08.842 Other juvenile arthritis, left hand M08.849 Other juvenile arthritis, unspecified hand M08.851 Other juvenile arthritis, right hip M08.852 Other juvenile arthritis, left hip M08.859 Other juvenile arthritis, unspecified hip M08.861 Other juvenile arthritis, right knee M08.862 Other juvenile arthritis, left knee M08.869 Other juvenile arthritis, unspecified knee M08.871 Other juvenile arthritis, right ankle and ft M08.872 Other juvenile arthritis, left ankle and ft M08.879 Other juvenile arthritis, unspecified ankle and ft M08.88 Other juvenile arthritis, ther specified site M08.89 Other juvenile arthritis, multiple sites M08.90 Juvenile arthritis, unspecified, unspecified site M08.911 Juvenile arthritis, unspecified, right shulder M08.912 Juvenile arthritis, unspecified, left shulder M08.919 Juvenile arthritis, unspecified, unspecified shulder M08.921 Juvenile arthritis, unspecified, right elbw M08.922 Juvenile arthritis, unspecified, left elbw M08.929 Juvenile arthritis, unspecified, unspecified elbw M08.931 Juvenile arthritis, unspecified, right wrist M08.932 Juvenile arthritis, unspecified, left wrist M08.939 Juvenile arthritis, unspecified, unspecified wrist M08.941 Juvenile arthritis, unspecified, right hand M08.942 Juvenile arthritis, unspecified, left hand M08.949 Juvenile arthritis, unspecified, unspecified hand M08.951 Juvenile arthritis, unspecified, right hip M08.952 Juvenile arthritis, unspecified, left hip M08.959 Juvenile arthritis, unspecified, unspecified hip M08.961 Juvenile arthritis, unspecified, right knee M08.962 Juvenile arthritis, unspecified, left knee Mda Health Plan, Inc. Medical Necessity Criteria Page 17/18
M08.969 Juvenile arthritis, unspecified, unspecified knee M08.971 Juvenile arthritis, unspecified, right ankle and ft M08.972 Juvenile arthritis, unspecified, left ankle and ft M08.979 Juvenile arthritis, unspecified, unspecified ankle and ft M08.98 Juvenile arthritis, unspecified, vertebrae M08.99 Juvenile arthritis, unspecified, multiple sites R59.0 Lcalized enlarged lymph ndes R59.1 Generalized enlarged lymph ndes R59.9 Enlarged lymph ndes, unspecified Z85.72 Persnal histry f nn-hdgkin lymphmas 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. 100-2), 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: http://www.cms.gv/medicare-cveragedatabase/search/advanced-search.aspx. Additinal indicatins may be cvered at the discretin f the health plan. Medicare Part B Cvered Diagnsis Cdes (applicable t existing NCD/LCD): N/A 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 Palmett GBA, 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) K (13 & 14) NY, CT, MA, RI, VT, ME, NH Nvitas Slutins, Inc. Natinal Gvernment Services, Inc. (NGS) 15 KY, OH CGS Administratrs, LLC Mda Health Plan, Inc. Medical Necessity Criteria Page 18/18