Q5103 — Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical records must document the basis for each diagnosis and that diagnoses follow recognized standards (eg, American College of Rheumatology guidelines).
- Medical records must include patient weight when needed to determine appropriate dosing.
- Medical records must document evaluation for latent tuberculosis infection with a medical evaluation and TB test, and initiation of latent TB treatment prior to infliximab when indicated.
- Medical records must document disease‑specific relevant symptoms and signs that are being treated and monitored to assess response to treatment.
Key Coverage Criteria
- Infliximab and its FDA‑approved biosimilars are covered when administered in accordance with the FDA‑approved label or recognized compendia for labeled and off‑label uses.
- Covered for Crohn's disease when medical records document disease‑specific signs/symptoms (eg, abdominal pain, diarrhea, fistulae) and dosing per label or compendia; retreatment is covered if prior initial treatment produced reduction in clinical signs and symptoms.
- Covered for rheumatoid arthritis when prescribed per label/compendia and medical record documents concomitant methotrexate use or a documented contraindication to methotrexate.
- Covered for plaque psoriasis when documentation shows chronic, severe, extensive, or disabling disease (eg, percent BSA, PASI, or PDI) and the patient will have close physician follow‑up and monitoring.
- Claims for pyoderma gangrenosum with coexisting inflammatory bowel disease are covered when the claim includes both primary and secondary ICD‑10‑CM diagnosis codes documenting pyoderma gangrenosum and IBD.
- NGS covers leuprolide acetate (LHRH analog) as palliative treatment of advanced breast carcinoma in premenopausal and perimenopausal women.
16 Active Policies
A52423 — Billing and Coding: Infliximab and biosimilars
J06
L33394 — Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J06
AETNA-CPB-0788 — Alzheimer's Disease: Experimental Treatments
A56432 — Billing and Coding: Infliximab
L35677 — Infliximab
Related Codes
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