Billing and Coding: Infliximab and biosimilars

Infliximab and its FDA‑approved biosimilars are covered when used per the FDA label or recognized compendia for labeled and accepted off‑label indications, with specific indications including Crohn's disease, rheumatoid arthritis, plaque psoriasis, and pyoderma gangrenosum with coexisting IBD when properly documented. Coverage requires disease‑specific documentation (diagnosis basis, weight for dosing, TB evaluation and treatment when indicated, prior 3‑month conventional therapy failure) and adherence to dose/frequency in the FDA insert; deviations, missing required claim diagnosis codes, or lack of required documentation (eg, RA response beyond 30 weeks) may lead to denial.

"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."

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