Rituximab (Rituxan®) is a genetically engineered chimeric murine/human monoclonal antibody. It binds specifically to the antigen CD20 (human B-lymphocyte-restricted differentiation antigen, Bp35). This antigen is a hydrophobic transmembrane protein that is located on pre-B and mature B lymphocytes. It is also expressed on more than 90 percent of B-cell non-Hodgkin's lymphomas, but it is not expressed on hematopoietic stem cells, pro-B cells, normal plasma cells, or other normal tissues.
Rituximab and hyaluronidase human (Rituxan Hycela™) is a combination of rituximab and hyaluronidase human in a subcutaneous formulation that is given by a healthcare professional after an initial administration of intravenous rituximab (Rituxan). These two products are different formulations and cannot be used interchangeably.
Rituximab-abbs (Truxima®), rituximab-arrx (Riabni™), and rituximab-pvvr (Ruxience™) are biosimilars of rituximab (Rituxan).
Preferred Products
Rituximab-arrx (Riabni) and rituximab-pvvr (Ruxience) are the preferred rituximab biosimilars for individuals initiating new therapy for oncologic indications when the clinical criteria within this policy are met. A non-preferred product will be considered when the individual has a documented therapy failure after an adequate therapeutic trial of a preferred product, or the preferred product has not been tolerated or is contraindicated.
Rituximab-arrx (Riabni) and rituximab-pvvr (Ruxience) are the preferred rituximab biosimilars for Rheumatoid Arthritis (RA) indications when the clinical criteria within this policy are met. A non-preferred product will be considered when the individual has a documented therapy failure after an adequate therapeutic trial of a preferred product, or the preferred product has not been tolerated or is contraindicated.
Adequate therapeutic trial is defined as 180 days from first dose of therapy at Food and Drug Administration (FDA) or compendia based therapeutic doses of preferred product.
New therapy is defined as no previous utilization within the last 180 calendar days.
Q5119 |
Q5123 |
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Rituximab (Rituxan)
Rituximab (Rituxan) may be considered medically necessary for ANY of the following indications:
Antineutrophil Cytoplasmic Antibody‒Associated Vasculitides (Granulomatosis with Polyangiitis [Wegener Granulomatosis] and Microscopic Polyangiitis)
Chronic Lymphocytic Leukemia (CLL)
Non-Hodgkin’s Lymphoma (NHL)
Treatment of NHL in any of the following:
Pemphigus Vulgaris (PV)
Rheumatoid Arthritis (RA)
Compendia Sources
Rituximab (Rituxan) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations
Reauthorization Criteria for rituximab (Rituxan)
Continuation of therapy with rituximab (Rituxan) for non-oncologic indications may be considered medically necessary when the following criteria is met:
The use of rituximab (Rituxan) for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.
J9312 |
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Other clinically supported indications
Rituximab (Rituxan) may be considered medically necessary for ANY of the following 2b or higher off-label indications:
Autoimmune Hemolytic Anemia (AIHA)
Churg-Strauss Syndrome (Eosinophilic Granulomatosis with Polyangiitis)
Epstein-Barr virus disease; Prophylaxis - Hemopoietic stem cell transplant
Evans syndrome (Pediatric only)
Hemophilia
Hepatitis C Virus‒Associated Cryoglobulinemic Vasculitis
Idiopathic Membranous Nephropathy
Immune thrombocytopenia, previously treated (Pediatric only)
Inflammatory Myopathy (Idiopathic)
Lupus Nephritis
Microscopic polyarteritis nodosa (Adult only)
Minimal change disease (Pediatric only)
Multiple Sclerosis (Primary Progressive)
Multiple Sclerosis (Relapsing Remitting)
Myasthenia Gravis
Myopathy, Idiopathic Inflammatory
Neuromyelitis Optica
Pemphigoid Diseases
Pemphigus Diseases
Pemphigus Foliaceus
Sjögren’s Syndrome (Primary)
Systemic Lupus Erythematosus
Systemic Sclerosis (Scleroderma)
Thrombocytopenic purpura (Idiopathic)
Thrombotic Thrombocytopenic Purpura
Reauthorization Criteria for rituximab (Rituxan)
Continuation of therapy with rituximab (Rituxan) for non-oncologic indications may be considered medically necessary when the following criteria is met:
The use of rituximab for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.
J9312 |
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Rituximab and hyaluronidase human (Rituxan Hycela®) subcutaneous (SC) – healthcare administered
Rituximab and hyaluronidase human (Rituxan Hycela) may be considered medically necessary for adult individuals 18 years of age and older only after individual has received at least one full dose of a rituximab product by intravenous infusion for ANY of the following indications:
Chronic lymphoid leukemia (CLL)
Diffuse Large B-Cell Lymphoma (DLBCL)
Follicular lymphoma (FL)
Compendia Sources
Rituximab and hyaluronidase human (Rituxan Hycela®) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations
Individuals receiving rituximab and hyaluronidase human (Rituxan Hycela) cannot have a live vaccination prior to or during treatment with rituximab and hyaluronidase human (Rituxan Hycela).
The use of rituximab and hyaluronidase human (Rituxan Hycela) for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.
J9311 |
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Rituximab-abbs (Truxima) or rituximab-pvvr (Ruxience) may be considered medically necessary for the treatment of individuals 18 years and older for ANY of the following indications:
Chronic Lymphocytic Leukemia (CLL)
Granulomatosis with Polyangitis, Wegener’s Granulomatosis, and Microscopic Polyangiitis
Non-Hodgkin’s Lymphoma (NHL)
Rheumatoid Arthritis (RA)
Compendia Sources
Rituximab-abbs (Truxima) or rituximab-pvvr (Ruxience) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations.
Reauthorization Criteria for Rituximab-abbs (Truxima) or Rituximab-pvvr (Ruxience)
Continuation of therapy with rituximab-abbs (Truxima) or rituximab-pvvr (Ruxience) for non-oncologic indications may be considered medically necessary when the following criteria is met:
The use of rituximab-abbs (Truxima) or rituximab-pvvr (Ruxience) for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.
Q5115 |
Q5119 |
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Rituximab-arrx (Riabni) may be considered medically necessary for the treatment of individuals 18 years and older for ANY of the following indications:
Chronic Lymphocytic Leukemia (CLL)
Granulomatosis with Polyangitis, Wegener’s Granulomatosis, and Microscopic Polyangiitis
Non-Hodgkin’s Lymphoma (NHL)
Rheumatoid Arthritis (RA)
Compendia Sources
Rituximab-arrx (Riabni) may be considered medically necessary for treatment of any of the current category 1, 2A, or 2B NCCN recommendations
Reauthorization Criteria for rituximab-arrx (Riabni)
Continuation of therapy with rituximab-arrx (Riabni) for non-oncologic indications may be considered medically necessary when the following criteria is met:
The use of rituximab-arrx (Riabni) for all other indications not listed on this policy is considered experimental/investigational and therefore, not covered. Scientific evidence does not support the use for all other indications.
Q5123 |
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*Maintenance rituximab is not appropriate after bendamustine and rituximab therapy and has not been tested after VR-CAP (bortezomib, rituximab, cyclophosphamide, doxorubicin, and prednisone) or RBAC (rituximab, bendamustine and cytarabine) therapy.
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Highmark may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.
Refer to medical policy I-25 Desensitization Treatment for Heart and Renal Transplant for additional information.
Refer to Medical Policy I-249 Pennsylvania Cancer Treatment Mandate, for additional information.
Covered Diagnosis Codes for Procedure Code J9312
C79.32 |
C81.00 |
C81.01 |
C81.02 |
C81.03 |
C81.04 |
C81.05 |
C81.06 |
C81.07 |
C81.08 |
C81.09 |
C82.00 |
C82.01 |
C82.02 |
C82.03 |
C82.04 |
C82.05 |
C82.06 |
C82.07 |
C82.08 |
C82.09 |
C82.10 |
C82.11 |
C82.12 |
C82.13 |
C82.14 |
C82.15 |
C82.16 |
C82.17 |
C82.18 |
C82.19 |
C82.20 |
C82.21 |
C82.22 |
C82.23 |
C82.24 |
C82.25 |
C82.26 |
C82.27 |
C82.28 |
C82.29 |
C82.30 |
C82.31 |
C82.32 |
C82.33 |
C82.34 |
C82.35 |
C82.36 |
C82.37 |
C82.38 |
C82.39 |
C82.40 |
C82.41 |
C82.42 |
C82.43 |
C82.44 |
C82.45 |
C82.46 |
C82.47 |
C82.48 |
C82.49 |
C82.50 |
C82.51 |
C82.52 |
C82.53 |
C82.54 |
C82.55 |
C82.56 |
C82.57 |
C82.58 |
C82.59 |
C82.60 |
C82.61 |
C82.62 |
C82.63 |
C82.64 |
C82.65 |
C82.66 |
C82.67 |
C82.68 |
C82.69 |
C82.80 |
C82.81 |
C82.82 |
C82.83 |
C82.84 |
C82.85 |
C82.86 |
C82.87 |
C82.88 |
C82.89 |
C82.90 |
C82.91 |
C82.92 |
C82.93 |
C82.94 |
C82.95 |
C82.96 |
C82.97 |
C82.98 |
C82.99 |
C83.00 |
C83.01 |
C83.02 |
C83.03 |
C83.04 |
C83.05 |
C83.06 |
C83.07 |
C83.08 |
C83.09 |
C83.10 |
C83.11 |
C83.12 |
C83.13 |
C83.14 |
C83.15 |
C83.16 |
C83.17 |
C83.18 |
C83.19 |
C83.30 |
C83.31 |
C83.32 |
C83.33 |
C83.34 |
C83.35 |
C83.36 |
C83.37 |
C83.38 |
C83.39 |
C83.50 |
C83.51 |
C83.52 |
C83.53 |
C83.54 |
C83.55 |
C83.56 |
C83.57 |
C83.58 |
C83.59 |
C83.70 |
C83.71 |
C83.72 |
C83.73 |
C83.74 |
C83.75 |
C83.76 |
C83.77 |
C83.78 |
C83.79 |
C83.80 |
C83.81 |
C83.82 |
C83.83 |
C83.84 |
C83.85 |
C83.86 |
C83.87 |
C83.88 |
C83.89 |
C83.90 |
C83.91 |
C83.92 |
C83.93 |
C83.94 |
C83.95 |
C83.96 |
C83.97 |
C83.98 |
C83.99 |
C85.10 |
C85.11 |
C85.12 |
C85.13 |
C85.14 |
C85.15 |
C85.16 |
C85.17 |
C85.18 |
C85.19 |
C85.20 |
C85.21 |
C85.22 |
C85.23 |
C85.24 |
C85.25 |
C85.26 |
C85.27 |
C85.28 |
C85.29 |
C85.80 |
C85.81 |
C85.82 |
C85.83 |
C85.84 |
C85.85 |
C85.86 |
C85.87 |
C85.88 |
C85.89 |
C88.0 |
C88.4 |
C91.00 |
C91.01 |
C91.02 |
C91.10 |
C91.12 |
C91.40 |
C91.42 |
D36.0 |
D47.Z1 |
D47.Z2 |
D59.0 |
D59.10 |
D59.11 |
D59.12 |
D59.13 |
D59.19 |
D66 |
D69.3 |
D69.41 |
D69.42 |
D69.49 |
D89.811 |
D89.812 |
D89.813 |
G04.81 |
G35 |
G36.0 |
G37.0 |
G37.5 |
G37.81 |
G37.89 |
G60.8 |
G61.89 |
G62.89 |
G64 |
G70.00 |
G70.01 |
L10.0 |
L10.1 |
L10.2 |
L10.3 |
L10.4 |
L10.5 |
L10.81 |
L10.89 |
L12.0 |
L12.1 |
L12.2 |
L12.31 |
L12.35 |
L12.8 |
L13.8 |
L13.9 |
M05.011 |
M05.012 |
M05.021 |
M05.022 |
M05.031 |
M05.032 |
M05.041 |
M05.042 |
M05.051 |
M05.052 |
M05.061 |
M05.062 |
M05.071 |
M05.072 |
M05.09 |
M05.111 |
M05.112 |
M05.121 |
M05.122 |
M05.131 |
M05.132 |
M05.141 |
M05.142 |
M05.151 |
M05.152 |
M05.161 |
M05.162 |
M05.171 |
M05.172 |
M05.19 |
M05.211 |
M05.212 |
M05.221 |
M05.222 |
M05.231 |
M05.232 |
M05.241 |
M05.242 |
M05.251 |
M05.252 |
M05.261 |
M05.262 |
M05.271 |
M05.272 |
M05.29 |
M05.311 |
M05.312 |
M05.321 |
M05.322 |
M05.331 |
M05.332 |
M05.341 |
M05.342 |
M05.351 |
M05.352 |
M05.361 |
M05.362 |
M05.371 |
M05.372 |
M05.39 |
M05.411 |
M05.412 |
M05.421 |
M05.422 |
M05.431 |
M05.432 |
M05.441 |
M05.442 |
M05.451 |
M05.452 |
M05.461 |
M05.462 |
M05.471 |
M05.472 |
M05.49 |
M05.511 |
M05.512 |
M05.521 |
M05.522 |
M05.531 |
M05.532 |
M05.541 |
M05.542 |
M05.551 |
M05.552 |
M05.561 |
M05.562 |
M05.571 |
M05.572 |
M05.59 |
M05.611 |
M05.612 |
M05.621 |
M05.622 |
M05.631 |
M05.632 |
M05.641 |
M05.642 |
M05.651 |
M05.652 |
M05.661 |
M05.662 |
M05.671 |
M05.672 |
M05.69 |
M05.711 |
M05.712 |
M05.721 |
M05.722 |
M05.731 |
M05.732 |
M05.741 |
M05.742 |
M05.751 |
M05.752 |
M05.761 |
M05.762 |
M05.771 |
M05.772 |
M05.79 |
M05.811 |
M05.812 |
M05.821 |
M05.822 |
M05.831 |
M05.832 |
M05.841 |
M05.842 |
M05.851 |
M05.852 |
M05.861 |
M05.862 |
M05.871 |
M05.872 |
M05.89 |
M05.9 |
M06.011 |
M06.012 |
M06.021 |
M06.022 |
M06.031 |
M06.032 |
M06.041 |
M06.042 |
M06.051 |
M06.052 |
M06.061 |
M06.062 |
M06.071 |
M06.072 |
M06.08 |
M06.09 |
M06.1 |
M06.211 |
M06.212 |
M06.221 |
M06.222 |
M06.231 |
M06.232 |
M06.241 |
M06.242 |
M06.251 |
M06.252 |
M06.262 |
M06.271 |
M06.272 |
M06.28 |
M06.29 |
M06.311 |
M06.312 |
M06.321 |
M06.322 |
M06.331 |
M06.332 |
M06.341 |
M06.342 |
M06.351 |
M06.352 |
M06.361 |
M06.362 |
M06.371 |
M06.372 |
M06.38 |
M06.39 |
M06.811 |
M06.812 |
M06.821 |
M06.822 |
M06.831 |
M06.832 |
M06.841 |
M06.842 |
M06.851 |
M06.852 |
M06.861 |
M06.862 |
M06.871 |
M06.872 |
M06.88 |
M06.89 |
M06.9 |
M30.0 |
M30.1 |
M30.2 |
M30.8 |
M31.1 |
M31.30 |
M31.31 |
M31.7 |
M32.0 |
M32.10 |
M32.11 |
M32.12 |
M32.13 |
M32.14 |
M32.15 |
M32.19 |
M32.8 |
M32.9 |
M33.20 |
M33.21 |
M33.22 |
M33.29 |
M33.90 |
M33.91 |
M33.92 |
M33.93 |
M33.99 |
M34.0 |
M34.1 |
M34.2 |
M34.81 |
M34.82 |
M34.83 |
M34.9 |
M35.00 |
M35.01 |
M35.02 |
M35.03 |
M35.04 |
M35.09 |
N01.0 |
N01.1 |
N01.2 |
N02.0 |
N02.1 |
N02.2 |
N02.3 |
N02.5 |
N02.8 |
N02.9 |
N02.B1 |
N02.B2 |
N02.B3 |
N02.B4 |
N02.B5 |
N02.B6 |
N02.B9 |
N03.0 |
N03.2 |
N04.0 |
N04.1 |
N04.20 |
N04.21 |
N04.22 |
N04.29 |
N04.3 |
N04.4 |
N04.5 |
N04.6 |
N04.7 |
N04.8 |
N04.9 |
N05.0 |
N05.2 |
N07.0 |
N07.1 |
N07.2 |
N08 |
R59.0 |
R59.1 |
R59.9 |
T86.09 |
Covered Diagnosis Codes for Procedure Code J9311
C82.00 |
C82.01 |
C82.02 |
C82.03 |
C82.04 |
C82.05 |
C82.06 |
C82.07 |
C82.08 |
C82.09 |
C82.10 |
C82.11 |
C82.12 |
C82.13 |
C82.14 |
C82.15 |
C82.16 |
C82.17 |
C82.18 |
C82.19 |
C82.20 |
C82.21 |
C82.22 |
C82.23 |
C82.24 |
C82.25 |
C82.26 |
C82.27 |
C82.28 |
C82.29 |
C82.30 |
C82.31 |
C82.32 |
C82.33 |
C82.34 |
C82.35 |
C82.36 |
C82.37 |
C82.38 |
C82.39 |
C82.40 |
C82.41 |
C82.42 |
C82.43 |
C82.44 |
C82.45 |
C82.46 |
C82.47 |
C82.48 |
C82.49 |
C82.50 |
C82.51 |
C82.52 |
C82.53 |
C82.54 |
C82.55 |
C82.56 |
C82.57 |
C82.58 |
C82.59 |
C82.60 |
C82.61 |
C82.62 |
C82.63 |
C82.64 |
C82.65 |
C82.66 |
C82.67 |
C82.68 |
C82.69 |
C82.80 |
C82.81 |
C82.82 |
C82.83 |
C82.84 |
C82.85 |
C82.86 |
C82.87 |
C82.88 |
C82.89 |
C82.90 |
C82.91 |
C82.92 |
C82.93 |
C82.94 |
C82.95 |
C82.96 |
C82.97 |
C82.98 |
C82.99 |
C83.00 |
C83.01 |
C83.02 |
C83.03 |
C83.04 |
C83.05 |
C83.06 |
C83.07 |
C83.08 |
C83.09 |
C83.10 |
C83.11 |
C83.12 |
C83.13 |
C83.14 |
C83.15 |
C83.16 |
C83.17 |
C83.18 |
C83.19 |
C83.30 |
C83.31 |
C83.32 |
C83.33 |
C83.34 |
C83.35 |
C83.36 |
C83.37 |
C83.38 |
C83.39 |
C83.80 |
C83.81 |
C83.82 |
C83.83 |
C83.84 |
C83.85 |
C83.86 |
C83.87 |
C83.88 |
C83.89 |
C85.20 |
C85.21 |
C85.22 |
C85.23 |
C85.24 |
C85.25 |
C85.26 |
C85.27 |
C85.28 |
C85.29 |
C85.80 |
C85.81 |
C85.82 |
C85.83 |
C85.84 |
C85.85 |
C85.86 |
C85.87 |
C85.88 |
C85.89 |
C88.4 |
C91.10 |
C91.12 |
C91.40 |
C91.42 |
D36.0 |
D47.Z1 |
D47.Z2 |
R59.0 |
R59.1 |
R59.9 |
Covered Diagnosis Codes for Q5115
C82.00 |
C82.01 |
C82.02 |
C82.03 |
C82.04 |
C82.05 |
C82.06 |
C82.07 |
C82.08 |
C82.09 |
C82.10 |
C82.11 |
C82.12 |
C82.13 |
C82.14 |
C82.15 |
C82.16 |
C82.17 |
C82.18 |
C82.19 |
C82.20 |
C82.21 |
C82.22 |
C82.23 |
C82.24 |
C82.25 |
C82.26 |
C82.27 |
C82.28 |
C82.29 |
C82.30 |
C82.31 |
C82.32 |
C82.33 |
C82.34 |
C82.35 |
C82.36 |
C82.37 |
C82.38 |
C82.39 |
C82.40 |
C82.41 |
C82.42 |
C82.43 |
C82.44 |
C82.45 |
C82.46 |
C82.47 |
C82.48 |
C82.49 |
C82.50 |
C82.51 |
C82.52 |
C82.53 |
C82.54 |
C82.55 |
C82.56 |
C82.57 |
C82.58 |
C82.59 |
C82.60 |
C82.61 |
C82.62 |
C82.63 |
C82.64 |
C82.65 |
C82.66 |
C82.67 |
C82.68 |
C82.69 |
C82.80 |
C82.81 |
C82.82 |
C82.83 |
C82.84 |
C82.85 |
C82.86 |
C82.87 |
C82.88 |
C82.89 |
C82.90 |
C82.91 |
C82.92 |
C82.93 |
C82.94 |
C82.95 |
C82.96 |
C82.97 |
C82.98 |
C82.99 |
C83.00 |
C83.01 |
C83.02 |
C83.03 |
C83.04 |
C83.05 |
C83.06 |
C83.07 |
C83.08 |
C83.09 |
C83.10 |
C83.11 |
C83.12 |
C83.13 |
C83.14 |
C83.15 |
C83.16 |
C83.17 |
C83.18 |
C83.19 |
C83.30 |
C83.31 |
C83.32 |
C83.33 |
C83.34 |
C83.35 |
C83.36 |
C83.37 |
C83.38 |
C83.39 |
C83.70 |
C83.71 |
C83.72 |
C83.73 |
C83.74 |
C83.75 |
C83.76 |
C83.77 |
C83.78 |
C83.79 |
C83.80 |
C83.81 |
C83.82 |
C83.83 |
C83.84 |
C83.85 |
C83.86 |
C83.87 |
C83.88 |
C83.89 |
C83.90 |
C83.91 |
C83.92 |
C83.93 |
C83.94 |
C83.95 |
C83.96 |
C83.97 |
C83.98 |
C83.99 |
C85.10 |
C85.11 |
C85.12 |
C85.13 |
C85.14 |
C85.15 |
C85.16 |
C85.17 |
C85.18 |
C85.19 |
C85.20 |
C85.21 |
C85.22 |
C85.23 |
C85.24 |
C85.25 |
C85.26 |
C85.27 |
C85.28 |
C85.29 |
C85.80 |
C85.81 |
C85.82 |
C85.83 |
C85.84 |
C85.85 |
C85.86 |
C85.87 |
C85.88 |
C85.89 |
C88.4 |
C91.10 |
C91.40 |
C91.42 |
D36.0 |
D47.Z1 |
D47.Z2 |
M05.011 |
M05.012 |
M05.021 |
M05.022 |
M05.031 |
M05.032 |
M05.041 |
M05.042 |
M05.051 |
M05.052 |
M05.061 |
M05.062 |
M05.071 |
M05.072 |
M05.09 |
M05.111 |
M05.112 |
M05.121 |
M05.122 |
M05.131 |
M05.132 |
M05.141 |
M05.142 |
M05.151 |
M05.152 |
M05.161 |
M05.162 |
M05.171 |
M05.172 |
M05.19 |
M05.211 |
M05.212 |
M05.221 |
M05.222 |
M05.231 |
M05.232 |
M05.241 |
M05.242 |
M05.251 |
M05.252 |
M05.261 |
M05.262 |
M05.271 |
M05.272 |
M05.29 |
M05.311 |
M05.312 |
M05.321 |
M05.322 |
M05.331 |
M05.332 |
M05.341 |
M05.342 |
M05.351 |
M05.352 |
M05.361 |
M05.362 |
M05.371 |
M05.372 |
M05.39 |
M05.411 |
M05.412 |
M05.421 |
M05.422 |
M05.431 |
M05.432 |
M05.441 |
M05.442 |
M05.451 |
M05.452 |
M05.461 |
M05.462 |
M05.471 |
M05.472 |
M05.49 |
M05.511 |
M05.512 |
M05.521 |
M05.522 |
M05.531 |
M05.532 |
M05.541 |
M05.542 |
M05.551 |
M05.552 |
M05.561 |
M05.562 |
M05.571 |
M05.572 |
M05.59 |
M05.611 |
M05.612 |
M05.621 |
M05.622 |
M05.631 |
M05.632 |
M05.641 |
M05.642 |
M05.651 |
M05.652 |
M05.661 |
M05.662 |
M05.671 |
M05.672 |
M05.69 |
M05.711 |
M05.712 |
M05.721 |
M05.722 |
M05.731 |
M05.732 |
M05.741 |
M05.742 |
M05.751 |
M05.752 |
M05.761 |
M05.762 |
M05.771 |
M05.772 |
M05.79 |
M05.811 |
M05.812 |
M05.821 |
M05.822 |
M05.831 |
M05.832 |
M05.841 |
M05.842 |
M05.851 |
M05.852 |
M05.861 |
M05.862 |
M05.871 |
M05.872 |
M05.89 |
M05.9 |
M06.011 |
M06.012 |
M06.021 |
M06.022 |
M06.031 |
M06.032 |
M06.041 |
M06.042 |
M06.051 |
M06.052 |
M06.061 |
M06.062 |
M06.071 |
M06.072 |
M06.08 |
M06.09 |
M06.1 |
M06.211 |
M06.212 |
M06.221 |
M06.222 |
M06.231 |
M06.232 |
M06.241 |
M06.242 |
M06.251 |
M06.252 |
M06.262 |
M06.271 |
M06.272 |
M06.28 |
M06.29 |
M06.311 |
M06.312 |
M06.321 |
M06.322 |
M06.331 |
M06.332 |
M06.341 |
M06.342 |
M06.351 |
M06.352 |
M06.361 |
M06.362 |
M06.371 |
M06.372 |
M06.38 |
M06.39 |
M06.811 |
M06.812 |
M06.821 |
M06.822 |
M06.831 |
M06.832 |
M06.841 |
M06.842 |
M06.851 |
M06.852 |
M06.861 |
M06.862 |
M06.871 |
M06.872 |
M06.88 |
M06.89 |
M06.9 |
M31.30 |
M31.31 |
M31.7 |
R59.0 |
R59.1 |
R59.9 |
|
|
|
|
|
Covered Diagnosis Codes for Q5119
C82.00 |
C82.01 |
C82.02 |
C82.03 |
C82.04 |
C82.05 |
C82.06 |
C82.07 |
C82.08 |
C82.09 |
C82.10 |
C82.11 |
C82.12 |
C82.13 |
C82.14 |
C82.15 |
C82.16 |
C82.17 |
C82.18 |
C82.19 |
C82.20 |
C82.21 |
C82.22 |
C82.23 |
C82.24 |
C82.25 |
C82.26 |
C82.27 |
C82.28 |
C82.29 |
C82.30 |
C82.31 |
C82.32 |
C82.33 |
C82.34 |
C82.35 |
C82.36 |
C82.37 |
C82.38 |
C82.39 |
C82.40 |
C82.41 |
C82.42 |
C82.43 |
C82.44 |
C82.45 |
C82.46 |
C82.47 |
C82.48 |
C82.49 |
C82.50 |
C82.51 |
C82.52 |
C82.53 |
C82.54 |
C82.55 |
C82.56 |
C82.57 |
C82.58 |
C82.59 |
C82.60 |
C82.61 |
C82.62 |
C82.63 |
C82.64 |
C82.65 |
C82.66 |
C82.67 |
C82.68 |
C82.69 |
C82.80 |
C82.81 |
C82.82 |
C82.83 |
C82.84 |
C82.85 |
C82.86 |
C82.87 |
C82.88 |
C82.89 |
C82.90 |
C82.91 |
C82.92 |
C82.93 |
C82.94 |
C82.95 |
C82.96 |
C82.97 |
C82.98 |
C82.99 |
C83.00 |
C83.01 |
C83.02 |
C83.03 |
C83.04 |
C83.05 |
C83.06 |
C83.07 |
C83.08 |
C83.09 |
C83.10 |
C83.11 |
C83.12 |
C83.13 |
C83.14 |
C83.15 |
C83.16 |
C83.17 |
C83.18 |
C83.19 |
C83.30 |
C83.31 |
C83.32 |
C83.33 |
C83.34 |
C83.35 |
C83.36 |
C83.37 |
C83.38 |
C83.39 |
C83.70 |
C83.71 |
C83.72 |
C83.73 |
C83.74 |
C83.75 |
C83.76 |
C83.77 |
C83.78 |
C83.79 |
C83.80 |
C83.81 |
C83.82 |
C83.83 |
C83.84 |
C83.85 |
C83.86 |
C83.87 |
C83.88 |
C83.89 |
C83.90 |
C83.91 |
C83.92 |
C83.93 |
C83.94 |
C83.95 |
C83.96 |
C83.97 |
C83.98 |
C83.99 |
C85.10 |
C85.11 |
C85.12 |
C85.13 |
C85.14 |
C85.15 |
C85.16 |
C85.17 |
C85.18 |
C85.19 |
C85.20 |
C85.21 |
C85.22 |
C85.23 |
C85.24 |
C85.25 |
C85.26 |
C85.27 |
C85.28 |
C85.29 |
C85.80 |
C85.81 |
C85.82 |
C85.83 |
C85.84 |
C85.85 |
C85.86 |
C85.87 |
C85.88 |
C85.89 |
C88.4 |
C91.10 |
D36.0 |
D47.Z1 |
D47.Z2 |
M05.611 |
M05.612 |
M05.621 |
M05.622 |
M05.631 |
M05.632 |
M05.641 |
M05.642 |
M05.651 |
M05.652 |
M05.661 |
M05.662 |
M05.671 |
M05.672 |
M05.711 |
M05.712 |
M05.721 |
M05.722 |
M05.731 |
M05.732 |
M05.741 |
M05.742 |
M05.751 |
M05.752 |
M05.761 |
M05.762 |
M05.771 |
M05.772 |
M05.811 |
M05.812 |
M05.821 |
M05.822 |
M05.831 |
M05.832 |
M05.841 |
M05.842 |
M05.851 |
M05.852 |
M05.861 |
M05.862 |
M05.871 |
M05.872 |
M05.9 |
M06.00 |
M06.011 |
M06.012 |
M06.021 |
M06.022 |
M06.031 |
M06.032 |
M06.041 |
M06.042 |
M06.051 |
M06.052 |
M06.061 |
M06.062 |
M06.071 |
M06.072 |
M06.08 |
M06.09 |
M06.1 |
M31.30 |
M31.31 |
M31.7 |
R59.0 |
R59.1 |
R59.9 |
Covered Diagnosis Codes for Q5123
C82.00 |
C82.01 |
C82.02 |
C82.03 |
C82.04 |
C82.05 |
C82.06 |
C82.07 |
C82.08 |
C82.09 |
C82.10 |
C82.11 |
C82.12 |
C82.13 |
C82.14 |
C82.15 |
C82.16 |
C82.17 |
C82.18 |
C82.19 |
C82.20 |
C82.21 |
C82.22 |
C82.23 |
C82.24 |
C82.25 |
C82.26 |
C82.27 |
C82.28 |
C82.29 |
C82.30 |
C82.31 |
C82.32 |
C82.33 |
C82.34 |
C82.35 |
C82.36 |
C82.37 |
C82.38 |
C82.39 |
C82.40 |
C82.41 |
C82.42 |
C82.43 |
C82.44 |
C82.45 |
C82.46 |
C82.47 |
C82.48 |
C82.49 |
C82.50 |
C82.51 |
C82.52 |
C82.53 |
C82.54 |
C82.55 |
C82.56 |
C82.57 |
C82.58 |
C82.59 |
C82.60 |
C82.61 |
C82.62 |
C82.63 |
C82.64 |
C82.65 |
C82.66 |
C82.67 |
C82.68 |
C82.69 |
C82.80 |
C82.81 |
C82.82 |
C82.83 |
C82.84 |
C82.85 |
C82.86 |
C82.87 |
C82.88 |
C82.89 |
C82.90 |
C82.91 |
C82.92 |
C82.93 |
C82.94 |
C82.95 |
C82.96 |
C82.97 |
C82.98 |
C82.99 |
C83.00 |
C83.01 |
C83.02 |
C83.03 |
C83.04 |
C83.05 |
C83.06 |
C83.07 |
C83.08 |
C83.09 |
C83.10 |
C83.11 |
C83.12 |
C83.13 |
C83.14 |
C83.15 |
C83.16 |
C83.17 |
C83.18 |
C83.19 |
C83.30 |
C83.31 |
C83.32 |
C83.33 |
C83.34 |
C83.35 |
C83.36 |
C83.37 |
C83.38 |
C83.39 |
C83.70 |
C83.71 |
C83.72 |
C83.73 |
C83.74 |
C83.75 |
C83.76 |
C83.77 |
C83.78 |
C83.79 |
C83.80 |
C83.81 |
C83.82 |
C83.83 |
C83.84 |
C83.85 |
C83.86 |
C83.87 |
C83.88 |
C83.89 |
C83.90 |
C83.91 |
C83.92 |
C83.93 |
C83.94 |
C83.95 |
C83.96 |
C83.97 |
C83.98 |
C83.99 |
C85.10 |
C85.11 |
C85.12 |
C85.13 |
C85.14 |
C85.15 |
C85.16 |
C85.17 |
C85.18 |
C85.19 |
C85.20 |
C85.21 |
C85.22 |
C85.23 |
C85.24 |
C85.25 |
C85.26 |
C85.27 |
C85.28 |
C85.29 |
C85.80 |
C85.81 |
C85.82 |
C85.83 |
C85.84 |
C85.85 |
C85.86 |
C85.87 |
C85.88 |
C85.89 |
C88.4 |
C91.10 |
C91.40 |
C91.42 |
D36.0 |
D47.Z1 |
D47.Z2 |
M05.611 |
M05.612 |
M05.621 |
M05.622 |
M05.631 |
M05.632 |
M05.641 |
M05.642 |
M05.651 |
M05.652 |
M05.661 |
M05.662 |
M05.671 |
M05.672 |
M05.711 |
M05.712 |
M05.721 |
M05.722 |
M05.731 |
M05.732 |
M05.741 |
M05.742 |
M05.751 |
M05.752 |
M05.761 |
M05.762 |
M05.771 |
M05.772 |
M05.811 |
M05.812 |
M05.821 |
M05.822 |
M05.831 |
M05.832 |
M05.841 |
M05.842 |
M05.851 |
M05.852 |
M05.861 |
M05.862 |
M05.871 |
M05.872 |
M05.9 |
M06.00 |
M06.011 |
M06.012 |
M06.021 |
M06.022 |
M06.031 |
M06.032 |
M06.041 |
M06.042 |
M06.051 |
M06.052 |
M06.061 |
M06.062 |
M06.071 |
M06.072 |
M06.08 |
M06.09 |
M06.1 |
M31.30 |
M31.31 |
M31.7 |
R59.0 |
R59.1 |
R59.9 |
|
|
|
|
|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.