Q5109, Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Imaging and laboratory/biomarker data used in studies: brain CT or MRI, amyloid PET (e.g., florbetapir), cerebrospinal fluid (CSF) biomarkers (Aβ1-42, total tau, phospho-tau), and APOE ε4 genotyping when reported in trials.
- For some interventional procedures/trials, pre-procedure evaluations included medical/neurological and psychological examinations, depression rating scales (e.g., Montgomery–Asberg Depression Rating Scale), and lumbar puncture with CSF analysis.
- Documentation of prior/concurrent standard therapies (e.g., use of cholinesterase inhibitors and/or memantine) is often recorded in trials and may be relevant when considering investigational add-on therapies.
- None specified in this policy document. (The CPB lists investigational/experimental treatments and codes not covered; it does not define separate documentation requirements for coverage of the listed items.)
Key Coverage Criteria
- None specified. This Clinical Policy Bulletin addresses experimental treatments for Alzheimer's disease and lists treatments considered experimental and investigational (i.e., not established as effective) for this indication.
- No explicit covered indications are stated in this document. The document discusses potential therapeutic use in the following conditions:
- Alzheimer's disease (AD)
- mild cognitive impairment (MCI)
- amnestic MCI
- pre-clinical AD
11 Active Policies
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
AETNA-CPB-0341, Infliximab
AETNA-CPB-0422, Vitiligo
BCBSIL-RX501.051, Infliximab and Associated Biosimilars
BCBSIL-ADM1001.034, Specialty Medication Administration Site of Care
Related Codes
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