Q5104, Injection, infliximab-abda, biosimilar, (renflexis), 10 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
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.
- For biologic initiation, documentation must show inadequate response (lack of efficacy, adverse effects, or contraindication) to a 3‑month trial of appropriately dosed, disease‑specific conventional (non‑biologic) therapy.
- For plaque psoriasis, documentation should include percent body surface area affected, PASI score, PDI score, or other psoriasis assessment tools and documentation of planned close follow‑up; monitor for nonmelanoma skin cancer especially after prior prolonged phototherapy.
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.
- Ankylosing spondylitis (AS) — Proven/medically necessary when all of the following are met: For initial therapy: Diagnosis of ankylosing spondylitis (AS); Infliximab is dosed according to U.S. FDA labeled dosing for ankylosing spondylitis; Patient is not receiving infliximab in combination with a Targeted Immunomodulator (examples listed in policy); Initial authorization is for no more than 12 months. [...]
20 Active Policies
A52423, Billing and Coding: Infliximab and biosimilars
J6
PALMETTO-JJ-L35677, Infliximab
JJ
NGS-L33394, Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
JK
PALMETTO-JM-L35677, Infliximab
JM
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
AETNA-CPB-0341, Infliximab
BCBSIL-RX501.051, Infliximab and Associated Biosimilars
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
BCBSMT-RX501.051, Infliximab and Associated Biosimilars
BCBSMT-ADM1001.034, Specialty Medication Administration Site of Care
BCBSNM-RX501.051, Infliximab and Associated Biosimilars
BCBSNM-ADM1001.034, Specialty Medication Administration Site of Care
BCBSOK-RX501.051, Infliximab and Associated Biosimilars
BCBSOK-ADM1001.034, Specialty Medication Administration Site of Care
UMR-POL-UMR-infliximab-remicade-inflectra, Infliximab (Avsola, Inflectra, Remicade, & Renflexis)
UMR-POL-UMR-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
SUREST-POL-SUREST-infliximab-remicade-inflectra, Infliximab (Avsola, Inflectra, Remicade, & Renflexis)
UHC-POL-infliximab-remicade-inflectra, Infliximab (Avsola, Inflectra, Remicade, & Renflexis)
A56432, Billing and Coding: Infliximab
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
Related Codes
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