Cytokine and CAM Antagonists

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1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Actemra (Tocilizumab) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit te: Click the hyperlink to navigate directly to that section. Cimzia (Certolizumab pegol) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit te: Click the hyperlink to navigate directly to that section. July 31, 2015 Copyright 2015 Health Information Designs, LLC 1

2 Kineret (Anakinra) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit te: Click the hyperlink to navigate directly to that section. Ilaris (Canakinumab) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit te: Click the hyperlink to navigate directly to that section. Orencia (Abatacept) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit te: Click the hyperlink to navigate directly to that section. July 31, 2015 Copyright 2015 Health Information Designs, LLC 2

3 Simponi (Golimumab) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit te: Click the hyperlink to navigate directly to that section. Stelara (Ustekinumab) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit te: Click the hyperlink to navigate directly to that section. Xeljanz (Tofacitinib) Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes) References: clinical publications and sources relevant to this clinical edit te: Click the hyperlink to navigate directly to that section. July 31, 2015 Copyright 2015 Health Information Designs, LLC 3

4 Revision tes Review of ICD-9 and ICD-10 codes July 31, 2015 Copyright 2015 Health Information Designs, LLC 4

5 Actemra (Tocilizumab) Drugs Requiring Prior Authorization Actemra Label Name GCN ACTEMRA 162MG/0.9ML SYRINGE July 31, 2015 Copyright 2015 Health Information Designs, LLC 5

6 Actemra (Tocilizumab) Clinical Edit Criteria Logic 1. Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? [] Go to #2 [] Go to #5 2. Is the client greater than or equal to ( ) 18 years of age? [] Go to #3 [] Deny 3. Does the client have 1 claim for a TNF blocker in the last 180 days? [] Go to #7 [] Go to #4 4. Does the client have a contraindication to or is the client non-responsive to a TNF-blocker? [manual] [] Go to #7 [] Deny 5. Does the client have a diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis in the last 730 days? [] Go to #6 [] Deny 6. Is the client 2 years of age? [] Go to #7 [] Deny 7. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] Go to #8 8. Does the client have 1 claim for a TNF modifier in the last 14 days? [] Deny [] Approve (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 6

7 Actemra (Tocilizumab) Clinical Edit Criteria Logic Diagram Step 1 Does the client have a diagnosis of rheumatoid arthritis in the last 730 days? Step 5 Does the client have a diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis in the last 730 days? Step 6 Is the client 2 years of age? Step 2 Is the client 18 years of age? Step 3 Does the client have 1 claim for a TNF blocker in the last 180 days? Step 7 Does the client have an active infection (including Hepatitis B virus and/or tuberculosis)? Step 4 Step 8 Does the client have a contraindication to or is the client nonresponsive to a TNFblocker? [manual] Does the client have 1 claim for a TNF modifier in the last 14 days? Approve Request (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 7

8 Actemra (Tocilizumab) Clinical Edit Criteria Supporting Tables ICD-9 Code Step 1 (diagnosis of rheumatoid arthritis) Description 7140 RHEUMATOID ARTHRITIS Look back timeframe: 730 days 7142 OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT ICD-10 Code M0560 M05611 M05612 M05619 M05621 M05622 M05629 M05631 M05632 M05639 M05641 M05642 M05649 M05651 M05652 M05659 Description RHEUMATOID ARTHRITIS OF UNSPECIFIED SITE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS July 31, 2015 Copyright 2015 Health Information Designs, LLC 8

9 M05661 M05662 M05669 M05671 M05672 M05679 M0569 M0570 M05711 M05712 M05719 M05721 M05722 M05729 M05731 M05732 M05739 M05741 M05742 M05749 M05751 M05752 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days RHEUMATOID ARTHRITIS OF RIGHT KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF MULTIPLE SITES WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SITE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ELBOW WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ELBOW WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ELBOW WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT WRIST WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT WRIST WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED WRIST WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HAND WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HAND WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HAND WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HIP WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HIP WITHOUT ORGAN OR SYSTEMS INVOLVEMENT July 31, 2015 Copyright 2015 Health Information Designs, LLC 9

10 M05759 M05761 M05762 M05769 M05771 M05772 M05779 M0579 M0580 M05811 M05812 M05819 M05821 M05822 M05829 M05831 M05832 M05839 M05841 M05842 M05849 M05851 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HIP WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT KNEE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT KNEE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED KNEE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ANKLE AND FOOT WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ANKLE AND FOOT WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ANKLE AND FOOT WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF MULTIPLE SITES WITHOUT ORGAN OR SYSTEMS INVOLVEMENT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SITE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT SHOULDER OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT SHOULDER OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SHOULDER OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ELBOW OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ELBOW OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ELBOW OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT WRIST OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT WRIST OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED WRIST OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HAND OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HAND OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HAND OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT HIP July 31, 2015 Copyright 2015 Health Information Designs, LLC 10

11 M05852 M05859 M05861 M05862 M05869 M05871 M05872 M05879 M0589 M059 M0600 M06011 M06012 M06019 M06021 M06022 M06029 M06031 M06032 M06039 M06041 M06042 M06049 M06051 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT HIP OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED HIP OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT KNEE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT KNEE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED KNEE OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT ANKLE AND FOOT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF LEFT ANKLE AND FOOT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED ANKLE AND FOOT OTHER RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF MULTIPLE SITES RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR, UNSPECIFIED RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR UNSPECIFIED SITE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT SHOULDER RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT SHOULDER RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED SHOULDER RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT ELBOW RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT ELBOW RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED ELBOW RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT WRIST RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT WRIST RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED WRIST RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT HAND RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT HAND RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED HAND RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT HIP July 31, 2015 Copyright 2015 Health Information Designs, LLC 11

12 M06052 M06059 M06061 M06062 M06069 M06071 M06072 M06079 M0608 M0609 M061 M0680 M06811 M06812 M06819 M06821 M06822 M06829 M06831 M06832 M06839 M06841 M06842 M06849 M06851 M06852 M06859 M06861 M06862 M06869 M06871 M06872 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT HIP RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED HIP RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT KNEE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT KNEE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED KNEE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, RIGHT ANKLE AND FOOT RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, LEFT ANKLE AND FOOT RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR, UNSPECIFIED ANKLE AND FOOT RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR VERTEBRAE RHEUMATOID ARTHRITIS WITHOUT RHEUMATOID FACTOR MULTIPLE SITES ADULT-ONSET STILL'S DISEASE OTHER SPECIFIED RHEUMATOID ARTHRITIS UNSPECIFIED SITE OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT SHOULDER OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT ELBOW OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT ELBOW OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED ELBOW OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT WRIST OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT WRIST OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED WRIST OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT HAND OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT HAND OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED HAND OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT HIP OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT HIP OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED HIP OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT KNEE OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT KNEE OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED KNEE OTHER SPECIFIED RHEUMATOID ARTHRITIS, RIGHT ANKLE AND FOOT OTHER SPECIFIED RHEUMATOID ARTHRITIS, LEFT ANKLE AND FOOT July 31, 2015 Copyright 2015 Health Information Designs, LLC 12

13 M06879 M0688 M0689 M069 Step 1 (diagnosis of rheumatoid arthritis) Look back timeframe: 730 days OTHER SPECIFIED RHEUMATOID ARTHRITIS, UNSPECIFIED ANKLE AND FOOT OTHER SPECIFIED RHEUMATOID ARTHRITIS VERTEBRAE OTHER SPECIFIED RHEUMATOID ARTHRITIS MULTIPLE SITES RHEUMATOID ARTHRITIS, UNSPECIFIED Step 3 (prior therapy with a TNF blocker) Look back timeframe: 180 days GCN Description CIMZIA 200MG VIAL KIT CIMZIA 200MG/ML SYRINGE KIT ENBREL 25MG KIT ENBREL 25MG/0.5ML SYRINGE ENBREL 50MG/ML SURECLICK SYRINGE ENBREL 50MG/ML SYRINGE HUMIRA 20MG/0.4ML SYRINGE HUMIRA 40MG/0.8ML PEN HUMIRA 40MG/0.8ML SYRINGE HUMIRA STARTER PACK REMICADE 100MG VIAL SIMPONI 100MG/ML PEN INJECTOR SIMPONI 100MG/ML SYRINGE SIMPONI 50MG/0.5ML PEN INJECTOR SIMPONI 50MG/0.5ML SYRINGE SIMPONI ARIA 50MG/4ML VIAL Step 5 (diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis) ICD-9 Code Description Look back timeframe: 730 days POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS, CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS, ACUTE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS MONOARTICULAR JUVENILE RHEUMATOID ARTHRITIS July 31, 2015 Copyright 2015 Health Information Designs, LLC 13

14 Step 5 (diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis) Look back timeframe: 730 days ICD-10 Code M0800 M08011 M08012 M08019 M08021 M08022 M08029 M08031 M08032 M08039 M08041 M08042 M08049 M08051 M08052 M08059 M08061 M08062 M08069 M08071 M08072 M08079 M0808 M0809 M0820 M08211 M08212 M08219 Description UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS OF UNSPECIFIED SITE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT SHOULDER UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT SHOULDER UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT ELBOW UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT ELBOW UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ELBOW UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT WRIST UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT WRIST UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED WRIST UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT HAND UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT HAND UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HAND UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT HIP UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT HIP UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HIP UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT KNEE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT KNEE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED KNEE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, RIGHT ANKLE AND FOOT UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, LEFT ANKLE AND FOOT UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ANKLE AND FOOT UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS VERTEBRAE UNSPECIFIED JUVENILE RHEUMATOID ARTHRITIS MULTIPLE SITES JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET UNSPECIFIED SITE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT SHOULDER JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED SHOULDER July 31, 2015 Copyright 2015 Health Information Designs, LLC 14

15 M08221 M08222 M08229 M08231 M08232 M08239 M08241 M08242 M08249 M08251 M08252 M08259 M08261 M08262 M08269 M08271 M08272 M08279 M0828 M0829 M083 M0840 M08411 Step 5 (diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis) Look back timeframe: 730 days JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED ELBOW JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT WRIST JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT WRIST JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED WRIST JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT HAND JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT HAND JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED HAND JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT HIP JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT HIP JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED HIP JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT KNEE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT KNEE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED KNEE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, RIGHT ANKLE AND FOOT JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, LEFT ANKLE AND FOOT JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET, UNSPECIFIED ANKLE AND FOOT JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET VERTEBRAE JUVENILE RHEUMATOID ARTHRITIS WITH SYSTEMIC ONSET MULTIPLE SITES JUVENILE RHEUMATOID POLYARTHRITIS (SERONEGATIVE) PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS UNSPECIFIED SITE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT SHOULDER July 31, 2015 Copyright 2015 Health Information Designs, LLC 15

16 M08412 M08419 M08421 M08422 M08429 M08431 M08432 M08439 M08441 M08442 M08449 M08451 M08452 M08459 M08461 M08462 M08469 M08471 M08472 M08479 M0848 Step 5 (diagnosis of polyarticular idiopathic arthritis or systemic juvenile idiopathic arthritis) Look back timeframe: 730 days PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT SHOULDER PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED SHOULDER PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT ELBOW PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT ELBOW PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ELBOW PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT WRIST PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT WRIST PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED WRIST PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT HAND PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT HAND PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HAND PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT HIP PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT HIP PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED HIP PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT KNEE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT KNEE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED KNEE PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, RIGHT ANKLE AND FOOT PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, LEFT ANKLE AND FOOT PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS, UNSPECIFIED ANKLE AND FOOT PAUCIARTICULAR JUVENILE RHEUMATOID ARTHRITIS VERTEBRAE ICD-9 Code Description Step 7 (active infection) Look back timeframe: 180 days VIRAL HEPATITIS B WITH HEPATIC COMA, ACUTE OR UNSPECIFIED, WITHOUT MENTION OF HEPATITIS DELTA VIRAL HEPATITIS B WITH HEPATIC COMA, ACUTE OR UNSPECIFIED, WITH HEPATITIS DELTA July 31, 2015 Copyright 2015 Health Information Designs, LLC 16

17 Step 7 (active infection) Look back timeframe: 180 days CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITHOUT HEPATITIS DELTA CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITH HEPATITIS DELTA VIRAL HEPATITIS B WITHOUT MENTION OF HEPATIC COMA, ACUTE OR UNSPECIFIED, WITHOUT MENTION OF HEPATITIS DELTA VIRAL HEPATITIS B WITHOUT MENTION OF HEPATIC COMA, ACUTE OR UNSPECIFIED, WITH HEPATITIS DELTA CHRONIC VIRAL HEPATITIS B WITHOUT MENTION OF HEPATIC COMA WITHOUT MENTION OF HEPATITIS DELTA CHRONIC VIRAL HEPATITIS B WITHOUT MENTION OF HEPATIC COMA WITH HEPATITIS DELTA PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED PRIMARY TUBERCULOUS INFECTION, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE PRIMARY TUBERCULOUS INFECTION, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) PRIMARY TUBERCULOUS INFECTION, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY PRIMARY TUBERCULOUS INFECTION, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE PRIMARY TUBERCULOUS INFECTION, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY PRIMARY TUBERCULOUS INFECTION, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, UNSPECIFIED TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] July 31, 2015 Copyright 2015 Health Information Designs, LLC 17

18 Step 7 (active infection) Look back timeframe: 180 days OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, UNSPECIFIED OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY OTHER PRIMARY PROGRESSIVE TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, UNSPECIFIED PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY PRIMARY TUBERCULOUS INFECTION, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF LUNG, INFILTRATIVE, UNSPECIFIED TUBERCULOSIS OF LUNG, INFILTRATIVE, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF LUNG, INFILTRATIVE, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOSIS OF LUNG, INFILTRATIVE, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF LUNG, INFILTRATIVE, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE July 31, 2015 Copyright 2015 Health Information Designs, LLC 18

19 Step 7 (active infection) Look back timeframe: 180 days TUBERCULOSIS OF LUNG, INFILTRATIVE, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF LUNG, INFILTRATIVE, TUBERCLE BACILLI NOT FOUND BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF LUNG, NODULAR, UNSPECIFIED TUBERCULOSIS OF LUNG, NODULAR, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF LUNG, NODULAR, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOSIS OF LUNG, NODULAR, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF LUNG, NODULAR, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOSIS OF LUNG, NODULAR, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF LUNG, NODULAR, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF LUNG WITH CAVITATION, UNSPECIFIED TUBERCULOSIS OF LUNG WITH CAVITATION, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF LUNG WITH CAVITATION, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOSIS OF LUNG WITH CAVITATION, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF LUNG WITH CAVITATION, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOSIS OF LUNG WITH CAVITATION, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF LUNG WITH CAVITATION, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF BRONCHUS, UNSPECIFIED TUBERCULOSIS OF BRONCHUS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF BRONCHUS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) July 31, 2015 Copyright 2015 Health Information Designs, LLC 19

20 Step 7 (active infection) Look back timeframe: 180 days TUBERCULOSIS OF BRONCHUS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF BRONCHUS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND IN BACTERIAL CULTURE TUBERCULOSIS OF BRONCHUS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF BRONCHUS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS FIBROSIS OF LUNG, UNSPECIFIED TUBERCULOUS FIBROSIS OF LUNG, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS FIBROSIS OF LUNG, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS FIBROSIS OF LUNG, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS FIBROSIS OF LUNG, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS FIBROSIS OF LUNG, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS FIBROSIS OF LUNG, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS BRONCHIECTASIS, UNSPECIFIED TUBERCULOUS BRONCHIECTASIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS BRONCHIECTASIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS BRONCHIECTASIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS BRONCHIECTASIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS BRONCHIECTASIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS BRONCHIECTASIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS PNEUMONIA [ANY FORM], UNSPECIFIED TUBERCULOUS PNEUMONIA [ANY FORM], BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE July 31, 2015 Copyright 2015 Health Information Designs, LLC 20

21 Step 7 (active infection) Look back timeframe: 180 days TUBERCULOUS PNEUMONIA [ANY FORM], BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS PNEUMONIA [ANY FORM], TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PNEUMONIA [ANY FORM], TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PNEUMONIA [ANY FORM], TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS PNEUMONIA [ANY FORM], TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS PNEUMOTHORAX, UNSPECIFIED TUBERCULOUS PNEUMOTHORAX, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS PNEUMOTHORAX, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS PNEUMOTHORAX, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PNEUMOTHORAX, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS PNEUMOTHORAX, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS PNEUMOTHORAX, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] OTHER SPECIFIED PULMONARY TUBERCULOSIS, UNSPECIFIED OTHER SPECIFIED PULMONARY TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE OTHER SPECIFIED PULMONARY TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) OTHER SPECIFIED PULMONARY TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY OTHER SPECIFIED PULMONARY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE OTHER SPECIFIED PULMONARY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY OTHER SPECIFIED PULMONARY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] July 31, 2015 Copyright 2015 Health Information Designs, LLC 21

22 Step 7 (active infection) Look back timeframe: 180 days PULMONARY TUBERCULOSIS, UNSPECIFIED, UNSPECIFIED PULMONARY TUBERCULOSIS, UNSPECIFIED, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE PULMONARY TUBERCULOSIS, UNSPECIFIED, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) PULMONARY TUBERCULOSIS, UNSPECIFIED, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY PULMONARY TUBERCULOSIS, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE PULMONARY TUBERCULOSIS, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY PULMONARY TUBERCULOSIS, UNSPECIFIED, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS PLEURISY, UNSPECIFIED TUBERCULOUS PLEURISY, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS PLEURISY, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS PLEURISY, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS PLEURISY, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS PLEURISY, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS PLEURISY, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, UNSPECIFIED TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY July 31, 2015 Copyright 2015 Health Information Designs, LLC 22

23 Step 7 (active infection) Look back timeframe: 180 days TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOSIS OF INTRATHORACIC LYMPH NODES, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, UNSPECIFIED ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY ISOLATED TRACHEAL OR BRONCHIAL TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] TUBERCULOUS LARYNGITIS, UNSPECIFIED TUBERCULOUS LARYNGITIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE TUBERCULOUS LARYNGITIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) TUBERCULOUS LARYNGITIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY TUBERCULOUS LARYNGITIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE TUBERCULOUS LARYNGITIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY TUBERCULOUS LARYNGITIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, UNSPECIFIED OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONE OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION UNKNOWN (AT PRESENT) July 31, 2015 Copyright 2015 Health Information Designs, LLC 23

24 Step 7 (active infection) Look back timeframe: 180 days OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, TUBERCLE BACILLI FOUND (IN SPUTUM) BY MICROSCOPY OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY, BUT FOUND BY BACTERIAL CULTURE OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED HISTOLOGICALLY OTHER SPECIFIED RESPIRATORY TUBERCULOSIS, TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION, BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS [INOCULATION OF ANIMALS] 4846 PNEUMONIA IN ASPERGILLOSIS 1363 PNEUMOCYSTOSIS ICD-10 Code B160 B161 B162 B169 B180 B181 B1910 B1911 A150 A154 A155 A156 A157 A158 A159 B440 B441 B447 B449 B59 Description ACUTE HEPATITIS B WITH DELTA-AGENT WITH HEPATIC COMA ACUTE HEPATITIS B WITH DELTA-AGENT WITHOUT HEPATIC COMA ACUTE HEPATITIS B WITHOUT DELTA-AGENT WITH HEPATIC COMA ACUTE HEPATITIS B WITHOUT DELTA-AGENT AND WITHOUT HEPATIC COMA CHRONIC VIRAL HEPATITIS B WITH DELTA-AGENT CHRONIC VIRAL HEPATITIS B WITHOUT DELTA-AGENT UNSPECIFIED VIRAL HEPATITIS B WITHOUT HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS B WITH HEPATIC COMA TUBERCULOSIS OF LUNG TUBERCULOSIS OF INTRATHORACIC LYMPH NODES TUBERCULOSIS OF LARYNX, TRACHEA AND BRONCHUS TUBERCULOUS PLEURISY PRIMARY RESPIRATORY TUBERCULOSIS OTHER RESPIRATORY TUBERCULOSIS RESPIRATORY TUBERCULOSIS UNSPECIFIED INVASIVE PULMONARY ASPERGILLOSIS OTHER PULMONARY ASPERGILLOSIS DISSEMINATED ASPERGILLOSIS ASPERGILLOSIS, UNSPECIFIED PNEUMOCYSTOSIS July 31, 2015 Copyright 2015 Health Information Designs, LLC 24

25 Step 8 (therapy with a TNF modifier) Look back timeframe: 14 days GCN Description ARZERRA 1000MG/50ML VIAL ARZERRA 100MG/5ML VIAL KINERET 100MG/0.67ML SYRINGE ORENCIA 125MG/ML SYRINGE ORENCIA 250MG VIAL RITUXAN 10MG/ML VIAL July 31, 2015 Copyright 2015 Health Information Designs, LLC 25

26 Cimzia (Certolizumab pegol) Drugs Requiring Prior Authorization Cimzia Label Name GCN CIMZIA 200MG VIAL KIT CIMZIA 200MG/ML STARTER KIT July 31, 2015 Copyright 2015 Health Information Designs, LLC 26

27 Cimzia (Certolizumab pegol) Clinical Edit Criteria Logic 1. Does the client have a diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis and/or rheumatoid arthritis in the last 730 days? [] Go to #2 [] Deny 2. Is the client greater than or equal to ( ) 18 years of age? [] Go to #3 [] Deny 3. Does the client have a history of a demyelinating disease (multiple sclerosis, optic neuritis, Guillain-Barre syndrome) in the last 365 days? [] Deny [] Go to #4 4. Does the client have a history of heart failure in the last 365 days? [] Deny [] Go to #5 5. Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? [] Deny [] Go to #6 6. Does the client have a history of hematologic abnormalities in the last 60 days? [] Deny [] Approve (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 27

28 Cimzia (Certolizumab pegol) Clinical Edit Criteria Logic Diagram Step 1 Does the client have a diagnosis of ankylosing spondylitis, Crohn s diseas, psoriatic arthritis and/ or rheumatoid arthritis in the last 730 days? Step 2 Is the client 18 years of age? Step 3 Does the client have a history of demyelinating disease in the last 365 days? Step 4 Does the client have a history of heart failure in the last 365 days? Step 5 Does the client have an active infection (including Hepatitis B virus and/or tuberculosis) in the last 180 days? Step 6 Does the client have a history of hematologic abnormalities in the last 60 days? Approve Request (365 days) July 31, 2015 Copyright 2015 Health Information Designs, LLC 28

29 Cimzia (Certolizumab pegol) Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) ICD-9 Code Description 7200 ANKYLOSING SPONDYLITIS Look back timeframe: 730 days 5550 REGIONAL ENTERITIS OF SMALL INTESTINE 5551 REGIONAL ENTERITIS OF LARGE INTESTINE 5552 REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE 5559 REGIONAL ENTRITIS OF UNSPECIFIED SITE 6960 PSORIATIC ARTHROPATHY 7140 RHEUMATOID ARTHRITIS 7142 OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT ICD-10 Code M450 M451 M452 M453 M454 M455 M456 M457 M458 M459 K5000 K50011 K50012 K50013 K50014 K50018 K50019 K5010 Description ANKYLOSING SPONDYLITIS OF MULTIPLE SITES IN SPINE ANKYLOSING SPONDYLITIS OF OCCIPITO-ATLANTO-AXIAL REGION ANKYLOSING SPONDYLITIS OF CERVICAL REGION ANKYLOSING SPONDYLITIS OF CERVICOTHORACIC REGION ANKYLOSING SPONDYLITIS OF THORACIC REGION ANKYLOSING SPONDYLITIS OF THORACOLUMBAR REGION ANKYLOSING SPONDYLITIS LUMBAR REGION ANKYLOSING SPONDYLITIS OF LUMBOSACRAL REGION ANKYLOSING SPONDYLITIS SACRAL AND SACROCOCCYGEAL REGION ANKYLOSING SPONDYLITIS OF UNSPECIFIED SITES IN SPINE CROHN'S DISEASE OF SMALL INTESTINE WITHOUT COMPLICATIONS CROHN'S DISEASE OF SMALL INTESTINE WITH RECTAL BLEEDING CROHN'S DISEASE OF SMALL INTESTINE WITH INTESTINAL OBSTRUCTION CROHN'S DISEASE OF SMALL INTESTINE WITH FISTULA CROHN'S DISEASE OF SMALL INTESTINE WITH ABSCESS CROHN'S DISEASE OF SMALL INTESTINE WITH OTHER COMPLICATION CROHN'S DISEASE OF SMALL INTESTINE WITH UNSPECIFIED COMPLICATIONS CROHN'S DISEASE OF LARGE INTESTINE WITHOUT COMPLICATIONS July 31, 2015 Copyright 2015 Health Information Designs, LLC 29

30 Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) K50111 K50112 K50113 K50114 K50118 K50119 K5080 K50811 K50812 K50813 K50814 K50818 K50819 K5090 K50911 K50912 K50913 K50914 K50918 K50919 L4050 L4051 L4052 L4054 L4059 M0560 M05611 M05612 Look back timeframe: 730 days CROHN'S DISEASE OF LARGE INTESTINE WITH RECTAL BLEEDING CROHN'S DISEASE OF LARGE INTESTINE WITH INTESTINAL OBSTRUCTION CROHN'S DISEASE OF LARGE INTESTINE WITH FISTULA CROHN'S DISEASE OF LARGE INTESTINE WITH ABSCESS CROHN'S DISEASE OF LARGE INTESTINE WITH OTHER COMPLICATION CROHN'S DISEASE OF LARGE INTESTINE WITH UNSPECIFIED COMPLICATIONS CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITHOUT COMPLICATIONS CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH RECTAL BLEEDING CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH INTESTINAL OBSTRUCTION CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH FISTULA CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH ABSCESS CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH OTHER COMPLICATION CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH UNSPECIFIED COMPLICATIONS CROHN'S DISEASE, UNSPECIFIED WITHOUT COMPLICATIONS CROHN'S DISEASE, UNSPECIFIED, WITH RECTAL BLEEDING CROHN'S DISEASE, UNSPECIFIED, WITH INTESTINAL OBSTRUCTION CROHN'S DISEASE, UNSPECIFIED, WITH FISTULA CROHN'S DISEASE, UNSPECIFIED, WITH ABSCESS CROHN'S DISEASE, UNSPECIFIED, WITH OTHER COMPLICATION CROHN'S DISEASE, UNSPECIFIED, WITH UNSPECIFIED COMPLICATIONS ARTHROPATHIC PSORIASIS UNSPECIFIED DISTAL INTERPHALANGEAL PSORIATIC ARTHROPATHY PSORIATIC ARTHRITIS MUTILANS PSORIATIC JUVENILE ARTHROPATHY OTHER PSORIATIC ARTHROPATHY RHEUMATOID ARTHRITIS OF UNSPECIFIED SITE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS July 31, 2015 Copyright 2015 Health Information Designs, LLC 30

31 Step 1 (diagnosis of ankylosing spondylitis, Crohn s disease, psoriatic arthritis, and/or rheumatoid arthritis) M05619 M05621 M05622 M05629 M05631 M05632 M05639 M05641 M05642 M05649 M05651 M05652 M05659 M05661 M05662 M05669 M05671 M05672 M05679 M0569 M0570 M05711 Look back timeframe: 730 days RHEUMATOID ARTHRITIS OF UNSPECIFIED SHOULDER WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED ELBOW WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED WRIST WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED HAND WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED HIP WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED KNEE WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF RIGHT ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF LEFT ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF UNSPECIFIED ANKLE AND FOOT WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS OF MULTIPLE SITES WITH INVOLVEMENT OF OTHER ORGANS AND SYSTEMS RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF UNSPECIFIED SITE WITHOUT ORGAN OR SYSTEMS INVOLVEMENT RHEUMATOID ARTHRITIS WITH RHEUMATOID FACTOR OF RIGHT SHOULDER WITHOUT ORGAN OR SYSTEMS INVOLVEMENT July 31, 2015 Copyright 2015 Health Information Designs, LLC 31

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