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
- Providers must follow the Local Coverage Determination (LCD) L35677 for clinical indications, coverage decisions, and documentation requirements for infliximab.
- Medical record documentation must show inadequate response, intolerance, or contraindication to specified conventional therapies (e.g., corticosteroids, aminosalicylates, immunosuppressants, NSAIDs, methotrexate, sulfasalazine, PUVA/UVB) where required by the indication.
- If infliximab is given without methotrexate, the patient's record must document the reason methotrexate cannot be used (intolerance or contraindication).
- Documentation of clinical response after the induction phase (usually after the 0, 2 and 6 week infusions) is required to justify ongoing maintenance therapy.
Key Coverage Criteria
- Infliximab is covered to induce and maintain clinical remission in adult and pediatric patients with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy (e.g., corticosteroids, aminosalicylates, immunosuppressive agents).
- Infliximab is covered to reduce draining enterocutaneous and rectovaginal fistulas and maintain fistula closure in fistulizing Crohn's disease, with induction infusions at weeks 0, 2 and 6 and subsequent treatment only if clinical response is documented.
- Infliximab is covered to reduce signs and symptoms, inhibit structural progression, and improve physical function in patients with psoriatic arthritis, typically given as induction at weeks 0, 2 and 6 with subsequent doses if response is demonstrated.
- Infliximab used in combination with methotrexate is covered to reduce signs and symptoms, inhibit structural damage and improve function in patients with moderately to severely active rheumatoid arthritis, with induction at 0, 2 and 6 weeks and maintenance approximately every 8 weeks.
- Infliximab is covered to reduce signs and symptoms in active ankylosing spondylitis, typically dosed at 0, 2 and 6 weeks with subsequent treatment if clinical response occurs.
- Infliximab is covered for adult patients with chronic severe plaque psoriasis (plaques covering at least 10% body surface area) who failed prior psoralen‑UVA or UVB therapy or failed/are contraindicated to conventional systemic therapies, with induction at 0, 2 and 6 weeks and maintenance every 8 weeks thereafter; patients must be closely monitored with regular physician follow-up.
9 Active Policies
AETNA-CPB-0341 — Infliximab
AETNA-CPB-0422 — Vitiligo
AETNA-CPB-0788 — Alzheimer's Disease: Experimental Treatments
A56432 — Billing and Coding: Infliximab
L35677 — Infliximab
Related Codes
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