Cytokine and CAM Antagonists

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Cytokine and CAM Antagonists"

Transcription

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

Cytokine and CAM Antagonists

Cytokine and CAM Antagonists 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

More information

Cytokine and CAM Antagonists

Cytokine and CAM Antagonists 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

More information

ICD 9 Codes Version 28

ICD 9 Codes Version 28 0010 Cholera due to vibrio cholerae 0011 Cholera due to vibrio cholerae el tor 0019 Cholera, unspecified 0020 Typhoid fever 0021 Paratyphoid fever A 0022 Paratyphoid fever B 0023 Paratyphoid fever C 0029

More information

Page 1 of 15 Origination Date: 09/14 Revision Date(s): 10/2015, 02/2016 Developed By: Medical Criteria Committee 10/28/2015

Page 1 of 15 Origination Date: 09/14 Revision Date(s): 10/2015, 02/2016 Developed By: Medical Criteria Committee 10/28/2015 Moda Health Plan, Inc. Medical Necessity Criteria Subject: Actemra (tocilizumab) Page 1 of 15 Origination Date: 09/14 Revision Date(s): 10/2015, 02/2016 Developed By: Medical Criteria Committee 10/28/2015

More information

Rheumatic Diseases, Psoriasis, and Crohn s Disease

Rheumatic Diseases, Psoriasis, and Crohn s Disease Rheumatic Diseases, Psoriasis, and Crohn s Disease What does this handout cover? This handout has information about rheumatic disease, psoriasis, and Crohn s disease. It also has information on how these

More information

Rheumatology ICD-10 documentation

Rheumatology ICD-10 documentation Rheumatology documentation Seven key impacts to documentation 1. Disease or disorder site 2. Acuity and/or encounter status of treatment 3. Etiology, causative agent, or disease type and injury/ poisoning

More information

Immune Modulating Drugs Prior Authorization Request Form

Immune Modulating Drugs Prior Authorization Request Form Patient: HPHC member ID #: Requesting provider: Phone: Servicing provider: Diagnosis: Contact for questions (name and phone #): Projected start and end date for requested Requesting provider NPI: Fax:

More information

RHEUMATOLOGY ICD-10 CROSSWALK

RHEUMATOLOGY ICD-10 CROSSWALK RHEUMATOLOGY ICD-10 CROSSWALK ICD is revised periodically and is currently in its tenth edition and will be implemented in the United States on October 1, 2015. There is an annual minor update and three-yearly

More information

DISEASE-MODIFYING ANTIRHEUMATIC DRUG THERAPY FOR RHEUMATOID ARTHRITIS

DISEASE-MODIFYING ANTIRHEUMATIC DRUG THERAPY FOR RHEUMATOID ARTHRITIS DISEASE-MODIFYING ANTIRHEUMATIC DRUG THERAPY FOR RHEUMATOID ARTHRITIS APPLICATIONS OBJECTIVE Purpose of Measure: ELIGIBLE POPULATION Which members are included? STANDARD OF CARE NCQA APPROVED CODES HEDIS

More information

Top 50 ICD-10-Codes Description ICD-9-CM Code ICD-10-CM Code 724.5 727.3

Top 50 ICD-10-Codes Description ICD-9-CM Code ICD-10-CM Code 724.5 727.3 Description ICD-9-CM Code ICD-10-CM Code Backache unspecified 724.5 M54.89 Other dorsalgia Excludes1: o dorsalgia in thoracic region (M54.6) o low back pain (M54.5) M54.9 Dorsalgia, unspecified Other bursitis

More information

Rheumatology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Rheumatology

Rheumatology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Rheumatology Rheumatology ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Rheumatology Chapter 12: Diseases of Skin and Subcutaneous Tissue ICD-10-CM introduces a new term, androgenic alopecia. Pressure

More information

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY

2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY Measure #337: Tuberculosis Prevention for Psoriasis,Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier National Quality Strategy Domain: Effective Clincal Care

More information

MEDICATION GUIDE HUMIRA

MEDICATION GUIDE HUMIRA MEDICATION GUIDE HUMIRA (Hu-MARE-ah) (adalimumab) injection Read the Medication Guide that comes with HUMIRA before you start taking it and each time you get a refill. There may be new information. This

More information

DIAGNOSIS CODE LONG DESCRIPTION SHORT DESCRIPTION 0010 Cholera due to vibrio cholerae Cholera d/t vib cholerae 0011 Cholera due to vibrio cholerae el

DIAGNOSIS CODE LONG DESCRIPTION SHORT DESCRIPTION 0010 Cholera due to vibrio cholerae Cholera d/t vib cholerae 0011 Cholera due to vibrio cholerae el DIAGNOSIS CODE LONG DESCRIPTION SHORT DESCRIPTION 0010 Cholera due to vibrio cholerae Cholera d/t vib cholerae 0011 Cholera due to vibrio cholerae el tor Cholera d/t vib el tor 0019 Cholera, unspecified

More information

You can find the PsA treatment support you want. You don t have to do this alone.

You can find the PsA treatment support you want. You don t have to do this alone. For adults with active Psoriatic arthritis (Ps a) There is a way forward. You can find the PsA treatment support you want. You don t have to do this alone. Indication: CIMZIA is approved for the treatment

More information

Drug Therapy Guidelines: Humira (adalimumab)

Drug Therapy Guidelines: Humira (adalimumab) Drug Therapy Guidelines: Humira (adalimumab) Effective Date: 5/1/08 Committee Review Date: 1/6/01, 9/18/01, 1/15/02, 1/7/03, 1/20/04, 1/18/05, 12/7/05, 10/15/06, 7/2/07, 11/5/07, 3/25/08 Policy Statements:

More information

You can find the PsA treatment support you want. You don t have to do this alone.

You can find the PsA treatment support you want. You don t have to do this alone. For adults with active Psoriatic arthritis (Ps a) There is a way forward. You can find the PsA treatment support you want. You don t have to do this alone. Indication: CIMZIA is approved for the treatment

More information

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES `I. Requirements for Prior Authorization of Cytokine and CAM Antagonists

MEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES `I. Requirements for Prior Authorization of Cytokine and CAM Antagonists MEDICAL ASSISTANCE HBOOK `I. Requirements for Prior Authorization of Cytokine and CAM Antagonists A. Prescriptions That Require Prior Authorization All prescriptions for Cytokine and CAM Antagonists must

More information

LCD for Erythrocyte Sedimentation Rate (ESR)

LCD for Erythrocyte Sedimentation Rate (ESR) LCD for Erythrocyte Sedimentation Rate (ESR) Applicable CPT Code(s): 85651 Sedimentation Rate, Erythrocyte; Non-Automated 85652 Sedimentation Rate, Erythrocyte; Automated ICD-9 Codes that Support Medical

More information

Rheumatoid Arthritis Information

Rheumatoid Arthritis Information Rheumatoid Arthritis Information Definition Rheumatoid arthritis (RA) is a long-term disease that leads to inflammation of the joints and surrounding tissues. It can also affect other organs. Alternative

More information

MEDICATION GUIDE. ACTEMRA (AC-TEM-RA) (tocilizumab) Solution for Intravenous Infusion

MEDICATION GUIDE. ACTEMRA (AC-TEM-RA) (tocilizumab) Solution for Intravenous Infusion MEDICATION GUIDE ACTEMRA (AC-TEM-RA) (tocilizumab) Solution for Intravenous Infusion ACTEMRA (AC-TEM-RA) (tocilizumab) Injection, Solution for Subcutaneous Administration Read this Medication Guide before

More information

MEDICATION GUIDE REMICADE (Rem-eh-kaid) (infliximab) Read the Medication Guide that comes with REMICADE before you receive the first treatment, and

MEDICATION GUIDE REMICADE (Rem-eh-kaid) (infliximab) Read the Medication Guide that comes with REMICADE before you receive the first treatment, and MEDICATION GUIDE REMICADE (Rem-eh-kaid) (infliximab) Read the Medication Guide that comes with REMICADE before you receive the first treatment, and before each time you get a treatment of REMICADE. This

More information

California SB 486 Needle Disposal Plan for SIMPONI (golimumab)

California SB 486 Needle Disposal Plan for SIMPONI (golimumab) California SB 486 Needle Disposal Plan for SIMPONI (golimumab) This describes the process in place for the end-of-life management of SIMPONI self-injection devices. SIMPONI (golimumab) is a drug for treatment

More information

Biologic Treatments for Rheumatoid Arthritis

Biologic Treatments for Rheumatoid Arthritis Biologic Treatments Rheumatoid Arthritis (also known as cytokine inhibitors, TNF inhibitors, IL 1 inhibitor, or Biologic Response Modifiers) Description Biologics are new class of drugs that have been

More information

CLINICAL POLICY Department: Medical Management Document Name: Rheumatoid & Juvenile Arthritis and Ankylosing Spondylitis Treatments

CLINICAL POLICY Department: Medical Management Document Name: Rheumatoid & Juvenile Arthritis and Ankylosing Spondylitis Treatments Page: 1 of 18 IMPORTANT REMINDER This Clinical Policy has been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration of generally accepted

More information

M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified M06.00 Rheumatoid arthritis without rheumatoid factor, unspecified site M06.

M05.9 Rheumatoid arthritis with rheumatoid factor, unspecified M06.00 Rheumatoid arthritis without rheumatoid factor, unspecified site M06. Rheumatology ICD-9 ICD-10 V58.69 Z79.3 Long term (current) use of hormonal contraceptives Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy 714.0 M05.40

More information

Critical Issues in School Health Arthritis in the School Setting. Lawrence Zemel MD Tegan Willard RN Connecticut Children s

Critical Issues in School Health Arthritis in the School Setting. Lawrence Zemel MD Tegan Willard RN Connecticut Children s Critical Issues in School Health Arthritis in the School Setting Lawrence Zemel MD Tegan Willard RN Connecticut Children s Juvenile Rheumatoid Idiopathic Arthritis Definition of JRA (JIA) Persistent arthritis

More information

Medical Drug Monitoring ICD-10-CM Sign and Symptom Codes

Medical Drug Monitoring ICD-10-CM Sign and Symptom Codes Medical Drug Monitoring ICD-10-CM Sign and Symptom s The ICD-10-CM codes listed below are commonly associated with LabCorp and MedTox Laboratories for medical drug monitoring and were selected based on

More information

Medicines for Rheumatoid. Arthritis. A Review of the Research for Adults

Medicines for Rheumatoid. Arthritis. A Review of the Research for Adults Medicines for Rheumatoid Arthritis A Review of the Research for Adults Is This Information Right for Me? Yes, this summary is for you if: Your doctor* has told you that you have rheumatoid (pronounced

More information

General Thoracic Surgery ICD9 to ICD10 Crosswalks. C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

General Thoracic Surgery ICD9 to ICD10 Crosswalks. C34.11 Malignant neoplasm of upper lobe, right bronchus or lung ICD-9 Code ICD-9 Description ICD-10 Code ICD-10 Description 150.3 Malignant neoplasm of upper third of esophagus C15.3 Malignant neoplasm of upper third of esophagus 150.4 Malignant neoplasm of middle

More information

Cytokine and CAM Antagonists and Related Agents Review 01/22/2010

Cytokine and CAM Antagonists and Related Agents Review 01/22/2010 Cytokine and CAM Antagonists and Related Agents Review 01/22/2010 Copyright 2005-2010 by Provider Synergies, L.L.C. All rights reserved. Printed in the United States of America. All rights reserved. No

More information

E08.621 Diabetes mellitus due to underlying condition with foot ulcer E09.621 Drug or chemical induced diabetes mellitus with foot ulcer E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11

More information

CPT codes are for information only; consult your payer organization for reimbursement information.

CPT codes are for information only; consult your payer organization for reimbursement information. CPT codes are for information only; consult your payer organization for reimbursement information. Coverage for Spirometry/Oximetry Spirometry is a component of pulmonary function testing (PFTs). PFTs

More information

Medication Guide Enbrel (en-brel) (etanercept)

Medication Guide Enbrel (en-brel) (etanercept) Medication Guide Enbrel (en-brel) (etanercept) Read the Medication Guide that comes with Enbrel before you start using it and each time you get a refill. There may be new information. This Medication Guide

More information

NURS 821 Alterations in the Musculoskeletal System. Rheumatoid Arthritis. Type III Hypersensitivity Response

NURS 821 Alterations in the Musculoskeletal System. Rheumatoid Arthritis. Type III Hypersensitivity Response NURS 821 Alterations in the Musculoskeletal System Margaret H. Birney PhD, RN Lecture 12 Part 2 Joint Disorders (cont d) Rheumatoid Arthritis Definition: Autoimmune disorder occurring in genetically sensitive

More information

CMS Limitations Guide Chest X-Ray Radiology Services

CMS Limitations Guide Chest X-Ray Radiology Services CMS Limitations Guide Chest X-Ray Radiology Services Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide provides you with all of the latest

More information

Do I need a physician referral? Yes, we see patients on referral from a health care provider.

Do I need a physician referral? Yes, we see patients on referral from a health care provider. FAQS FOR OFFICE POLICIES How do I get an appointment? New appointments are made by physician referral only. Your referring health care provided will call for the appointment for you. What do I need to

More information

Arthritis and Rheumatology Clinics of Kansas Patient Education. Reactive Arthritis (ReA) / Inflammatory Bowel Disease (IBD) Arthritis

Arthritis and Rheumatology Clinics of Kansas Patient Education. Reactive Arthritis (ReA) / Inflammatory Bowel Disease (IBD) Arthritis Arthritis and Rheumatology Clinics of Kansas Patient Education Reactive Arthritis (ReA) / Inflammatory Bowel Disease (IBD) Arthritis Introduction: For as long as scientists have studied rheumatic disease,

More information

Psoriatic Arthritis. having psoriatic arthritis.

Psoriatic Arthritis. having psoriatic arthritis. Psoriatic Arthritis having psoriatic arthritis. Psoriatic arthritis is a chronic disease characterized by a form of inflammation of the skin (psoriasis) and joints (inflammatory arthritis). Psoriasis is

More information

Remicade (infliximab)

Remicade (infliximab) DRUG POLICY Remicade (infliximab) Policy Number: 2015D004P Effective Date: 12/1/2015 Table of Contents Page COVERAGE RATIONALE... 1 BENEFIT CONSIDERATIONS... 3 BACKGROUND... 3 CLINICAL EVIDENCE... 4 U.S.

More information

Frequently Asked Questions

Frequently Asked Questions CIMZIA (certolizumab pegol) is approved for the treatment of adults with active psoriatic arthritis. Psoriatic Arthritis (PsA) Frequently Asked Questions This CIMZIA FAQ offers important highlights related

More information

SASKATCHEWAN FORMULARY BULLETIN Update to the 62nd Edition of the Saskatchewan Formulary

SASKATCHEWAN FORMULARY BULLETIN Update to the 62nd Edition of the Saskatchewan Formulary November 1, 2014 Bulletin #150 ISSN 1923-0761 SASKATCHEWAN FORMULARY BULLETIN Update to the 62nd Edition of the Saskatchewan Formulary New Exception Drug Status (EDS) Listings Effective November 1, 2014

More information

Local Coverage Determination (LCD) for Pulse Oximetry (L28296)

Local Coverage Determination (LCD) for Pulse Oximetry (L28296) Local Coverage Determination (LCD) for Pulse Oximetry (L28296) Contractor Information Contractor Name Palmetto GBA Back to Top Contractor Number 01102 Contractor Type MAC - Part B LCD Information Document

More information

There is a way forward.

There is a way forward. For adults with moderate to severe Rheumatoid Arthritis (RA) There is a way forward. You can find the RA treatment support you want. You don t have to do this alone. Indication: CIMZIA is approved for

More information

Chiropractic ICD-10 Common Codes List

Chiropractic ICD-10 Common Codes List Chiropractic ICD-10 Common Codes List This is a preliminary list of common ICD-10 codes for chiropractic diagnoses. This is a common code list to be used as a guide for coding and is not intended to represent

More information

DIVISION OF RHEUMATOLOGY DEPARTMENT OF MEDICINE UNIVERSITY OF WESTERN ONTARIO POSTGRADUATE EDUCTION ORTHOPAEDIC OFF-SERVICE GOALS & OBJECTIVES

DIVISION OF RHEUMATOLOGY DEPARTMENT OF MEDICINE UNIVERSITY OF WESTERN ONTARIO POSTGRADUATE EDUCTION ORTHOPAEDIC OFF-SERVICE GOALS & OBJECTIVES DIVISION OF RHEUMATOLOGY DEPARTMENT OF MEDICINE UNIVERSITY OF WESTERN ONTARIO POSTGRADUATE EDUCTION ORTHOPAEDIC OFF-SERVICE GOALS & OBJECTIVES GOAL #1 develop the ability to order and understand interpretation

More information

Psoriatic Arthritis. eorthopod.com 228 West Main St., Suite D Missoula, MT Phone: Fax:

Psoriatic Arthritis. eorthopod.com 228 West Main St., Suite D Missoula, MT Phone: Fax: A Patient s Guide to Psoriatic Arthritis 228 West Main St., Suite D Missoula, MT 59802-4345 Phone: 406-721-3072 Fax: 406-721-2619 info@eorthopod.com DISCLAIMER: The information in this booklet is compiled

More information

Anesthesia ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Anesthesia and Top 25 Codes

Anesthesia ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Anesthesia and Top 25 Codes Anesthesia ICD-10-CM Coding Tip Sheet Overview of Key Chapter Updates for Anesthesia and Top 25 Codes Chapter 2 Neoplasms (C00-D49) Classification improvements Code expansions Significant expansions or

More information

PART III: CONSUMER INFORMATION

PART III: CONSUMER INFORMATION PART III: CONSUMER INFORMATION Pr REMICADE (Infliximab) This leaflet is part III of a three-part "Product Monograph" published when REMICADE was approved for sale in Canada and is designed specifically

More information

History and Physical Examination for Rheumatic Disease for MUSC Students

History and Physical Examination for Rheumatic Disease for MUSC Students History and Physical Examination for Rheumatic Disease for MUSC Students Inflammatory vs. non-inflammatory arthritis Inflammatory Prolonged stiffness after rest Stiffness improved with use Warmth Prolonged

More information

Pain Management Top Diagnosis Codes (Crosswalk)

Pain Management Top Diagnosis Codes (Crosswalk) Pain Management Top s (Crosswalk) 274.00 Gout arthropathy, M1000 Idiopathic gout, unspecified site unspecified M10011 Idiopathic gout, right shoulder M10012 Idiopathic gout, left shoulder M10019 Idiopathic

More information

Billing and Coding Guidance Co-morbidities associated with morbid obesity

Billing and Coding Guidance Co-morbidities associated with morbid obesity Billing and Coding Guidance Co-morbidities associated with morbid obesity AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2014 American Medical Association. All Rights Reserved.

More information

ICD-10 Cheat Sheet Frequently Used ICD-10 Codes for Musculoskeletal Conditions *

ICD-10 Cheat Sheet Frequently Used ICD-10 Codes for Musculoskeletal Conditions * ICD-10 Cheat Sheet Frequently Used ICD-10 Codes for Musculoskeletal Conditions * Finding the ICD-10 equivalent for an ICD-9 code can be a challenge. This resource of frequently used codes can help when

More information

Psoriatic arthritis FACTSHEET

Psoriatic arthritis FACTSHEET 1 What is psoriatic arthritis? Psoriatic arthritis (PsA) is a disease where joints around the body become inflamed and sore. It can make moving about difficult and painful. People who have PsA also have

More information

MDC 1 DISEASES AND DISORDERS OF THE NERVOUS SYSTEM Implantation of chemotherapeutic agent Intracranial stents

MDC 1 DISEASES AND DISORDERS OF THE NERVOUS SYSTEM Implantation of chemotherapeutic agent Intracranial stents To assist the readers in identifying all changes that were made to the MS-DRGs as a result of comments, we developed the attached table that summaries those changes. MS-DRG Summary Table PRE-MDC Intestinal

More information

A Patient s Guide to Psoriatic Arthritis. Foot and Ankle Center of Massachusetts, P.C.

A Patient s Guide to Psoriatic Arthritis. Foot and Ankle Center of Massachusetts, P.C. A Patient s Guide to Psoriatic Arthritis Welcome to Foot and Ankle Center of Massachusetts, where we believe in accelerating your learning curve with educational materials that are clearly written and

More information

Let s talk about Arthritis

Let s talk about Arthritis Let s talk about Arthritis Osteoarthritis Rheumatoid Arthritis Kam Shojania, MD, FRCPC Clinical Professor and Head, St. Paul s, UBC and VGH Divisions of Rheumatology Slides with thanks to: Cheryl Koehn

More information

SPECIAL AUTHORIZATION GUIDELINES

SPECIAL AUTHORIZATION GUIDELINES 91B ALBERTA DRUG BENEFIT LIST SPECIAL AUTHORIZATION GUIDELINES 37BSpecial Authorization Policy 90BDrug Products Eligible for Consideration by Special Authorization Drug Products may be considered for coverage

More information

REFERENCE CODE GDHC503DFR PUBLICAT ION DATE DECEMBER 2014 METHOTREXATE (RHEUMATOID ARTHRITIS) - FORECAST AND MARKET ANALYSIS TO 2023

REFERENCE CODE GDHC503DFR PUBLICAT ION DATE DECEMBER 2014 METHOTREXATE (RHEUMATOID ARTHRITIS) - FORECAST AND MARKET ANALYSIS TO 2023 REFERENCE CODE GDHC503DFR PUBLICAT ION DATE DECEMBER 2014 METHOTREXATE (RHEUMATOID ARTHRITIS) - Executive Summary The table below provides the key metrics for Methotrexate in the 10MM (US, France, Germany,

More information

Medical Policy Anti-CCP Testing for Rheumatoid Arthritis

Medical Policy Anti-CCP Testing for Rheumatoid Arthritis Medical Policy Anti-CCP Testing for Rheumatoid Arthritis Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization

More information

-------------------------------CONTRAINDICATIONS------------------------------ Sepsis (4)

-------------------------------CONTRAINDICATIONS------------------------------ Sepsis (4) HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use Enbrel safely and effectively. See full prescribing information for Enbrel. Enbrel (etanercept) Solution

More information

biologics for the treatment of psoriasis

biologics for the treatment of psoriasis How to contact us The Psoriasis Association Dick Coles House 2 Queensbridge Northampton NN4 7BF tel: 08456 760 076 (01604) 251 620 fax: (01604) 251 621 email: mail@psoriasis-association.org.uk www.psoriasis-association.org.uk

More information

Alameda Alliance for Heath ICD-9 to ICD-10 TRANSLATION CODES E10.10

Alameda Alliance for Heath ICD-9 to ICD-10 TRANSLATION CODES E10.10 DIABETES ICD-9 CM ICD-9 CM Volume 1 - Diagnosis Description ICD-10 CM - Diagnosis Code ICD-10 CM - Diagnosis Description 250.00 Diabetes mellitus without mention of complication, type II or unspecified

More information

Rheumatoid Arthritis. Outline. Treatment Goal 4/10/2013. Clinical evaluation New treatment options Future research Discussion

Rheumatoid Arthritis. Outline. Treatment Goal 4/10/2013. Clinical evaluation New treatment options Future research Discussion Rheumatoid Arthritis Robert L. Talbert, Pharm.D., FCCP, BCPS University of Texas at Austin College of Pharmacy University of Texas Health Science Center at San Antonio Outline Clinical evaluation New treatment

More information

New biologic drugs for arthritis

New biologic drugs for arthritis 1 Biologic drugs (or biologics ) are used to treat many types of inflammatory arthritis such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, lupus and juvenile arthritis. They are

More information

Data M. Möhner et al. Fb 937 BfAA 2001. Compiled by Sebastian Pflugbeil 09 / 2013. Gesellschaft für Strahlenschutz e.v. Dr. Sebastian Pflugbeil

Data M. Möhner et al. Fb 937 BfAA 2001. Compiled by Sebastian Pflugbeil 09 / 2013. Gesellschaft für Strahlenschutz e.v. Dr. Sebastian Pflugbeil Health insurance certificate in the WISMUT mine 1985 1989 and comparison with German Democratic Republic (GDR, East Germany) reference data 1989 for s and for selected diagnoses (ICD-9 numbers) 100%: WISMUT

More information

Treatment of Rheumatoid Arthritis in the New Millennium. Neal I. Shparago, D.O., FACP, FACR

Treatment of Rheumatoid Arthritis in the New Millennium. Neal I. Shparago, D.O., FACP, FACR Treatment of Rheumatoid Arthritis in the New Millennium Neal I. Shparago, D.O., FACP, FACR What is RA? Symmetric inflammatory polyarthritis Rheumatoid factor positive in 80% Anti-CCP positive in approximately

More information

Arthritis in Children: Juvenile Rheumatoid Arthritis By Kerry V. Cooke

Arthritis in Children: Juvenile Rheumatoid Arthritis By Kerry V. Cooke Reading Comprehension Read the following essay on juvenile rheumatoid arthritis. Then use the information in the text to answer the questions that follow. Arthritis in Children: Juvenile Rheumatoid Arthritis

More information

RHEUMATOID ARTHRITIS Peek n Peak - 2016

RHEUMATOID ARTHRITIS Peek n Peak - 2016 RHEUMATOID ARTHRITIS Peek n Peak - 2016 General characteristics of Epidemiology Clinical manifestations Radiographic changes Treatment A 50 year-old obese white female comes to your office with a chief

More information

It is worth noting that people with psoriasis can also develop other forms of arthritis such as rheumatoid arthritis and osteoarthritis.

It is worth noting that people with psoriasis can also develop other forms of arthritis such as rheumatoid arthritis and osteoarthritis. Psoriatic Arthritis Main Colour - pantone 2597u Research - pantone 206u Children - pantone 123 4 What is psoriatic arthritis? Psoriatic arthritis is an inflammatory joint disease associated with psoriasis.

More information

Chiropractic ICD 9 Code List

Chiropractic ICD 9 Code List Use of valid ICD 9 codes, billed with appropriate and corresponding CPT codes, benefits providers by facilitating treatment authorization and claims payment. The use of valid and appropriate codes also

More information

CMS Limitations Guide Mammography & Bone Mass Measurement

CMS Limitations Guide Mammography & Bone Mass Measurement Starting October 1, 2015, CMS will update their existing medical necessity limitations on tests and procedures to correspond to ICD-10 codes. This limitations guide provides you with the latest changes.

More information

Patient Assistance Application for HUMIRA (adalimumab)

Patient Assistance Application for HUMIRA (adalimumab) The AbbVie Patient Assistance Foundation provides AbbVie medicines at no cost to patients experiencing financial difficulties. Eligible patients typically have no healthcare coverage for the requested

More information

Arthritis in Older Adults. Ewa Olech, M.D. University of Nevada School of Medicine Las Vegas, NV

Arthritis in Older Adults. Ewa Olech, M.D. University of Nevada School of Medicine Las Vegas, NV Arthritis in Older Adults Ewa Olech, M.D. University of Nevada School of Medicine Las Vegas, NV Objectives Examine the prevalence and course of arthritis in older adults Describe the different types of

More information

Therapy Trends: Rheumatoid Arthritis -- KOL Insight Module

Therapy Trends: Rheumatoid Arthritis -- KOL Insight Module Brochure More information from http://www.researchandmarkets.com/reports/2583544/ Therapy Trends: Rheumatoid Arthritis -- KOL Insight Module Description: What the future holds: Over the next few years,

More information

September 2008 [KT 168] Sub. Code: 2063 M.D. DEGREE EXAMINATION Branch XVII Tuberculosis and Respiratory Diseases NON-TUBERCULOSIS CHEST DISEASES Common to Part II Paper II - (Old /New/Revised Regulations)

More information

(Intro to Arthritis with a. Arthritis) Manager of Education & Services for the Vancouver Island Region of The Arthritis Society

(Intro to Arthritis with a. Arthritis) Manager of Education & Services for the Vancouver Island Region of The Arthritis Society Arthritis 101 (Intro to Arthritis with a Focus on Rheumatoid Arthritis) by Cari Taylor by Cari Taylor Manager of Education & Services for the Vancouver Island Region of The Arthritis Society What You Will

More information

Immune modulation in rheumatology. Geoff McColl University of Melbourne/Australian Rheumatology Association

Immune modulation in rheumatology. Geoff McColl University of Melbourne/Australian Rheumatology Association Immune modulation in rheumatology Geoff McColl University of Melbourne/Australian Rheumatology Association A traditional start to a presentation on biological agents in rheumatic disease is Plasma cell

More information

REMICADE (infliximab)

REMICADE (infliximab) HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use REMICADE safely and effectively. See full prescribing information for REMICADE. REMICADE (infliximab)

More information

Page 1 of 5 Origination Date: 09/14 Revision Date(s): 10/2015, 02/2016, 07/2016 Developed By: Medical Criteria Committee 09/2014

Page 1 of 5 Origination Date: 09/14 Revision Date(s): 10/2015, 02/2016, 07/2016 Developed By: Medical Criteria Committee 09/2014 Moda Health Plan, Inc. Medical Necessity Criteria Subject: Stelara (ustekinumab) Page 1 of 5 Origination Date: 09/14 Revision Date(s): 10/2015, 02/2016, 07/2016 Developed By: Medical Criteria Committee

More information

Non inflammatory joint diseases

Non inflammatory joint diseases Arthritis Inflammatory joint diseases -Diffuse connective tissue diseases -Rheumatoid arthritis (+juvenile rheumatoid arthritis) -Systemic erythematous lupus -Polymyositis/Dermatomyositis -Vasculopathies

More information

(THE CHANGING LANDSCAPE)

(THE CHANGING LANDSCAPE) Updating the therapeutic strategy in RA What is effective, what is changing in daily practice regarding the use of DMARDs and biological agents in the Balkan countries The Greek experience (THE CHANGING

More information

Methods for Measuring Dose Escalation in TNF Antagonists for Rheumatoid Arthritis Patients Treated in Routine Clinical Practice

Methods for Measuring Dose Escalation in TNF Antagonists for Rheumatoid Arthritis Patients Treated in Routine Clinical Practice Methods for Measuring Dose Escalation in TNF Antagonists for Rheumatoid Arthritis Patients Treated in Routine Clinical Practice Gu NY 1, Huang XY 2, Globe D 2, Fox KM 3 1 University of Southern California,

More information

Commercial Insight: Disease Modification in Rheumatoid Arthritis - Market awaits game changing therapies and strategies

Commercial Insight: Disease Modification in Rheumatoid Arthritis - Market awaits game changing therapies and strategies Brochure More information from http://www.researchandmarkets.com/reports/1504775/ Commercial Insight: Disease Modification in Rheumatoid Arthritis - Market awaits game changing therapies and strategies

More information

RESEARCH DIAGNOSTICS PHARMACEUTICALS

RESEARCH DIAGNOSTICS PHARMACEUTICALS RESEARCH DIAGNOSTICS PHARMACEUTICALS Therapeutic drug monitoring is vitally important to optimize therapy for all patients treated with biologicals. Routine measurement of serum drug levels brings both

More information

Rheumatoid Arthritis:

Rheumatoid Arthritis: Rheumatoid Arthritis Update 2014 Mark Hulsey, MD FACR Rheumatoid Arthritis Key Features Symptoms >6 weeks duration Often lasts the remainder of the patient s life Inflammatory synovitis Palpable synovial

More information

Jurisdiction South Carolina. Retirement Date N/A

Jurisdiction South Carolina. Retirement Date N/A Local Coverage Determination (LCD): Respiratory Therapy (Respiratory Care) (L31593) Contractor Information Contractor Name Palmetto GBA opens in Contract Number 11201 Contract Type MAC - Part A LCD Information

More information

The Janssen Biotech Support System. Getting patients started on STELARA

The Janssen Biotech Support System. Getting patients started on STELARA The Janssen Biotech Support System Getting patients started on STELARA 3 STEPS after identifying patients appropriate for STELARA (ustekinumab) STEP 1: Determine the correct dose STELARA is administered

More information

HIGHLIGHTS OF PRESCRIBING INFORMATION

HIGHLIGHTS OF PRESCRIBING INFORMATION HUMIRA - adalimumab injection, solution Abbott Laboratories ---------- HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use HUMIRA safely and effectively.

More information

ICD10 Chiropractic Diagnosis Codes

ICD10 Chiropractic Diagnosis Codes ICD10 Chiropractic Diagnosis Codes Disclaimer: When the ICD-10 code requires a 7th character, the code shown assumes "initial." Disclaimer: This information is based on the General Equivalency Mapping

More information

Appendix B: Provincial Case Definitions for Reportable Diseases

Appendix B: Provincial Case Definitions for Reportable Diseases Infectious Diseases Protocol Appendix B: Provincial Case Definitions for Reportable Diseases Disease: Tuberculosis Revised August 2015 Tuberculosis 1.0 Provincial Reporting Confirmed and suspect cases

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Health Technology Appraisal

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE. Health Technology Appraisal NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Health Technology Appraisal Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure

More information

(CIM-zee-uh) HIGHLIGHTS OF PRESCRIBING INFORMATION WARNING: SERIOUS INFECTIONS AND MALIGNANCY

(CIM-zee-uh) HIGHLIGHTS OF PRESCRIBING INFORMATION WARNING: SERIOUS INFECTIONS AND MALIGNANCY (CIM-zee-uh) HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use CIMZIA safely and effectively. See full prescribing information for CIMZIA. CIMZIA (certolizumab

More information

Stakeholder Insight: Rheumatoid arthritis - Rising competition by line and severity

Stakeholder Insight: Rheumatoid arthritis - Rising competition by line and severity Brochure More information from http://www.researchandmarkets.com/reports/1383065/ Stakeholder Insight: Rheumatoid arthritis - Rising competition by line and severity Description: Introduction Disease-modifying

More information

Introduction to ICD - 10. Andrea Devlin, CPMA, CPC Alta Partners, LLC 2015

Introduction to ICD - 10. Andrea Devlin, CPMA, CPC Alta Partners, LLC 2015 Introduction to ICD - 10 Andrea Devlin, CPMA, CPC Alta Partners, LLC 2015 Agenda Introduction Benefits of ICD-10 Features of ICD-10 ICD-9 vs. ICD-10 ICD-10 Structure Question & Answer Introducing ICD-10

More information

Medicines for Psoriatic Arthritis. A Review of the Research for Adults

Medicines for Psoriatic Arthritis. A Review of the Research for Adults Medicines for Psoriatic Arthritis A Review of the Research for Adults Is This Information Right for Me? Yes, this information is right for you if: Your doctor* has told you that you have psoriatic (pronounced

More information

CAUTION: FOR TRAINING PURPOSES ONLY. ABSOLUTELY NO WARRANTY IMPLIED.

CAUTION: FOR TRAINING PURPOSES ONLY. ABSOLUTELY NO WARRANTY IMPLIED. CAUTION: FOR TRAINING PURPOSES ONLY. ABSOLUTELY NO WARRANTY IMPLIED. DIAGNOSIS CODE LIST: ICD-10's only, Report page# 1 CODE DESCRIPTION -------------------------------------------------------------------

More information

Rheumatoid Arthritis. Compiled by Darreck My Healing Oils notes

Rheumatoid Arthritis. Compiled by Darreck My Healing Oils notes Rheumatoid Arthritis Compiled by Darreck My Healing Oils notes What is Rheumatoid Arthritis Rheumatoid arthritis (RA) is an autoimmune disease where the body's immune system attacks normal joint tissues,

More information

SECTION 3. Criteria for Special Authorization of Select Drug Products. Section 3 Criteria for Special Authorization of Select Drug Products

SECTION 3. Criteria for Special Authorization of Select Drug Products. Section 3 Criteria for Special Authorization of Select Drug Products SECTION 3 Criteria for Special Authorization of Select Drug Products Section 3 Criteria for Special Authorization of Select Drug Products CRITERIA FOR SPECIAL AUTHORIZATION OF SELECT DRUG PRODUCTS The

More information

UCB announces regulatory filings for Cimzia (certolizumab pegol) to treat psoriatic arthritis and axial spondyloarthritis

UCB announces regulatory filings for Cimzia (certolizumab pegol) to treat psoriatic arthritis and axial spondyloarthritis UCB announces regulatory filings for Cimzia (certolizumab pegol) to treat psoriatic arthritis and axial spondyloarthritis Filings with the US and the EU regulatory authorities to extend the marketing authorization

More information