Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 08.01.20j


Attachment:A

Policy #:08.01.20j

Description:ICD-10 Codes and Narratives

Title:Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



ICD-10 Codes and Narratives


ATEZOLIZUMAB (TECENTRIQ®) IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

C33 Malignant neoplasm of trachea

C34.00 Malignant neoplasm of unspecified main bronchus

C34.01 Malignant neoplasm of right main bronchus

C34.02 Malignant neoplasm of left main bronchus

C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

C34.12 Malignant neoplasm of upper lobe, left bronchus or lung

C34.2 Malignant neoplasm of middle lobe, bronchus or lung

C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31 Malignant neoplasm of lower lobe, right bronchus or lung

C34.32 Malignant neoplasm of lower lobe, left bronchus or lung

C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung

C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91 Malignant neoplasm of unspecified part of right bronchus or lung

C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

C61 Malignant neoplasm of prostate

C65.1 Malignant neoplasm of right renal pelvis

C65.2 Malignant neoplasm of left renal pelvis

C65.9 Malignant neoplasm of unspecified renal pelvis

C66.1 Malignant neoplasm of right ureter

C66.2 Malignant neoplasm of left ureter

C66.9 Malignant neoplasm of unspecified ureter

C67.0 Malignant neoplasm of trigone of bladder

C67.1 Malignant neoplasm of dome of bladder

C67.2 Malignant neoplasm of lateral wall of bladder

C67.3 Malignant neoplasm of anterior wall of bladder

C67.4 Malignant neoplasm of posterior wall of bladder

C67.5 Malignant neoplasm of bladder neck

C67.6 Malignant neoplasm of ureteric orifice

C67.7 Malignant neoplasm of urachus

C67.8 Malignant neoplasm of overlapping sites of bladder

C67.9 Malignant neoplasm of bladder, unspecified

C68.0 Malignant neoplasm of urethra

C68.1 Malignant neoplasm of paraurethral glands

C68.8 Malignant neoplasm of overlapping sites of urinary organs

C68.9 Malignant neoplasm of urinary organ, unspecified

NIVOLUMAB (OPDIVO®) IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

C00.0 Malignant neoplasm of external upper lip

C00.1 Malignant neoplasm of external lower lip

C00.2 Malignant neoplasm of external lip, unspecified

C00.3 Malignant neoplasm of upper lip, inner aspect

C00.4 Malignant neoplasm of lower lip, inner aspect

C00.5 Malignant neoplasm of lip, unspecified, inner aspect

C00.6 Malignant neoplasm of commissure of lip, unspecified

C00.8 Malignant neoplasm of overlapping sites of lip

C00.9 Malignant neoplasm of lip, unspecified

C01 Malignant neoplasm of base of tongue

C02.0 Malignant neoplasm of dorsal surface of tongue

C02.1 Malignant neoplasm of border of tongue

C02.2 Malignant neoplasm of ventral surface of tongue

C02.3 Malignant neoplasm of anterior two-thirds of tongue, part unspecified

C02.4 Malignant neoplasm of lingual tonsil

C02.8 Malignant neoplasm of overlapping sites of tongue

C02.9 Malignant neoplasm of tongue, unspecified

C03.0 Malignant neoplasm of upper gum

C03.1 Malignant neoplasm of lower gum

C03.9 Malignant neoplasm of gum, unspecified

C04.0 Malignant neoplasm of anterior floor of mouth

C04.1 Malignant neoplasm of lateral floor of mouth

C04.8 Malignant neoplasm of overlapping sites of floor of mouth

C04.9 Malignant neoplasm of floor of mouth, unspecified

C05.0 Malignant neoplasm of hard palate

C05.1 Malignant neoplasm of soft palate

C05.2 Malignant neoplasm of uvula

C05.8 Malignant neoplasm of overlapping sites of palate

C05.9 Malignant neoplasm of palate, unspecified

C06.0 Malignant neoplasm of cheek mucosa

C06.1 Malignant neoplasm of vestibule of mouth

C06.2 Malignant neoplasm of retromolar area

C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth

C06.89 Malignant neoplasm of overlapping sites of other parts of mouth

C06.9 Malignant neoplasm of mouth, unspecified

C09.0 Malignant neoplasm of tonsillar fossa

C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior)

C09.8 Malignant neoplasm of overlapping sites of tonsil

C09.9 Malignant neoplasm of tonsil, unspecified

C10.0 Malignant neoplasm of vallecula

C10.1 Malignant neoplasm of anterior surface of epiglottis

C10.2 Malignant neoplasm of lateral wall of oropharynx

C10.3 Malignant neoplasm of posterior wall of oropharynx

C10.4 Malignant neoplasm of branchial cleft

C10.8 Malignant neoplasm of overlapping sites of oropharynx

C10.9 Malignant neoplasm of oropharynx, unspecified

C11.0 Malignant neoplasm of superior wall of nasopharynx

C11.1 Malignant neoplasm of posterior wall of nasopharynx

C11.2 Malignant neoplasm of lateral wall of nasopharynx

C11.3 Malignant neoplasm of anterior wall of nasopharynx

C11.8 Malignant neoplasm of overlapping sites of nasopharynx

C11.9 Malignant neoplasm of nasopharynx, unspecified

C12 Malignant neoplasm of pyriform sinus

C13.0 Malignant neoplasm of postcricoid region

C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect

C13.2 Malignant neoplasm of posterior wall of hypopharynx

C13.8 Malignant neoplasm of overlapping sites of hypopharynx

C13.9 Malignant neoplasm of hypopharynx, unspecified

C14.0 Malignant neoplasm of pharynx, unspecified

C14.2 Malignant neoplasm of Waldeyer's ring

C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

C18.0 Malignant neoplasm of cecum

C18.1 Malignant neoplasm of appendix

C18.2 Malignant neoplasm of ascending colon

C18.3 Malignant neoplasm of hepatic flexure

C18.4 Malignant neoplasm of transverse colon

C18.5 Malignant neoplasm of splenic flexure

C18.6 Malignant neoplasm of descending colon

C18.7 Malignant neoplasm of sigmoid colon

C18.8 Malignant neoplasm of overlapping sites of colon

C18.9 Malignant neoplasm of colon, unspecified

C19 Malignant neoplasm of rectosigmoid junction

C20 Malignant neoplasm of rectum

C21.0 Malignant neoplasm of anus, unspecified

C21.1 Malignant neoplasm of anal canal

C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal

C31.0 Malignant neoplasm of maxillary sinus

C31.1 Malignant neoplasm of ethmoidal sinus

C31.2 Malignant neoplasm of frontal sinus

C31.3 Malignant neoplasm of sphenoid sinus

C31.8 Malignant neoplasm of overlapping sites of accessory sinuses

C31.9 Malignant neoplasm of accessory sinus, unspecified

C32.0 Malignant neoplasm of glottis

C32.1 Malignant neoplasm of supraglottis

C32.2 Malignant neoplasm of subglottis

C32.3 Malignant neoplasm of laryngeal cartilage

C32.8 Malignant neoplasm of overlapping sites of larynx

C32.9 Malignant neoplasm of larynx, unspecified

C33 Malignant neoplasm of trachea

C34.00 Malignant neoplasm of unspecified main bronchus

C34.01 Malignant neoplasm of right main bronchus

C34.02 Malignant neoplasm of left main bronchus

C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

C34.12 Malignant neoplasm of upper lobe, left bronchus or lung

C34.2 Malignant neoplasm of middle lobe, bronchus or lung

C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31 Malignant neoplasm of lower lobe, right bronchus or lung

C34.32 Malignant neoplasm of lower lobe, left bronchus or lung

C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung

C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91 Malignant neoplasm of unspecified part of right bronchus or lung

C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

C43.0 Malignant melanoma of lip

C43.10 Malignant melanoma of unspecified eyelid, including canthus

C43.111 Malignant melanoma of right upper eyelid, including canthus

C43.112 Malignant melanoma of right lower eyelid, including canthus

C43.121 Malignant melanoma of left upper eyelid, including canthus

C43.122 Malignant melanoma of left lower eyelid, including canthus

C43.20 Malignant melanoma of unspecified ear and external auricular canal

C43.21 Malignant melanoma of right ear and external auricular canal

C43.22 Malignant melanoma of left ear and external auricular canal

C43.30 Malignant melanoma of unspecified part of face

C43.31 Malignant melanoma of nose

C43.39 Malignant melanoma of other parts of face

C43.4 Malignant melanoma of scalp and neck

C43.51 Malignant melanoma of anal skin

C43.52 Malignant melanoma of skin of breast

C43.59 Malignant melanoma of other part of trunk

C43.60 Malignant melanoma of unspecified upper limb, including shoulder

C43.61 Malignant melanoma of right upper limb, including shoulder

C43.62 Malignant melanoma of left upper limb, including shoulder

C43.70 Malignant melanoma of unspecified lower limb, including hip

C43.71 Malignant melanoma of right lower limb, including hip

C43.72 Malignant melanoma of left lower limb, including hip

C43.8 Malignant melanoma of overlapping sites of skin

C43.9 Malignant melanoma of skin, unspecified

C44.42 Squamous cell carcinoma of skin of scalp and neck

C45.0 Mesothelioma of pleura

C51.0 Malignant neoplasm of labium majus

C51.1 Malignant neoplasm of labium minus

C51.2 Malignant neoplasm of clitoris

C51.8 Malignant neoplasm of overlapping sites of vulva

C51.9 Malignant neoplasm of vulva, unspecified

C52 Malignant neoplasm of vagina

C57.7 Malignant neoplasm of other specified female genital organs

C57.8 Malignant neoplasm of overlapping sites of female genital organs

C57.9 Malignant neoplasm of female genital organ, unspecified

C60.0 Malignant neoplasm of prepuce

C60.1 Malignant neoplasm of glans penis

C60.2 Malignant neoplasm of body of penis

C60.8 Malignant neoplasm of overlapping sites of penis

C60.9 Malignant neoplasm of penis, unspecified

C61 Malignant neoplasm of prostate

C63.00 Malignant neoplasm of unspecified epididymis

C63.01 Malignant neoplasm of right epididymis

C63.02 Malignant neoplasm of left epididymis

C63.10 Malignant neoplasm of unspecified spermatic cord

C63.11 Malignant neoplasm of right spermatic cord

C63.12 Malignant neoplasm of left spermatic cord

C63.2 Malignant neoplasm of scrotum

C63.7 Malignant neoplasm of other specified male genital organs

C63.8 Malignant neoplasm of overlapping sites of male genital organs

C63.9 Malignant neoplasm of male genital organ, unspecified

C64.1 Malignant neoplasm of right kidney, except renal pelvis

C64.2 Malignant neoplasm of left kidney, except renal pelvis

C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis

C65.1 Malignant neoplasm of right renal pelvis

C65.2 Malignant neoplasm of left renal pelvis

C65.9 Malignant neoplasm of unspecified renal pelvis

C66.1 Malignant neoplasm of right ureter

C66.2 Malignant neoplasm of left ureter

C66.9 Malignant neoplasm of unspecified ureter

C67.0 Malignant neoplasm of trigone of bladder

C67.1 Malignant neoplasm of dome of bladder

C67.2 Malignant neoplasm of lateral wall of bladder

C67.3 Malignant neoplasm of anterior wall of bladder

C67.4 Malignant neoplasm of posterior wall of bladder

C67.5 Malignant neoplasm of bladder neck

C67.6 Malignant neoplasm of ureteric orifice

C67.7 Malignant neoplasm of urachus

C67.8 Malignant neoplasm of overlapping sites of bladder

C67.9 Malignant neoplasm of bladder, unspecified

C68.0 Malignant neoplasm of urethra

C68.1 Malignant neoplasm of paraurethral glands

C68.8 Malignant neoplasm of overlapping sites of urinary organs

C68.9 Malignant neoplasm of urinary organ, unspecified

C69.00 Malignant neoplasm of unspecified conjunctiva

C69.01 Malignant neoplasm of right conjunctiva

C69.02 Malignant neoplasm of left conjunctiva

C69.10 Malignant neoplasm of unspecified cornea

C69.11 Malignant neoplasm of right cornea

C69.12 Malignant neoplasm of left cornea

C69.20 Malignant neoplasm of unspecified retina

C69.21 Malignant neoplasm of right retina

C69.22 Malignant neoplasm of left retina

C69.30 Malignant neoplasm of unspecified choroid

C69.31 Malignant neoplasm of right choroid

C69.32 Malignant neoplasm of left choroid

C69.40 Malignant neoplasm of unspecified ciliary body

C69.41 Malignant neoplasm of right ciliary body

C69.42 Malignant neoplasm of left ciliary body

C69.50 Malignant neoplasm of unspecified lacrimal gland and duct

C69.51 Malignant neoplasm of right lacrimal gland and duct

C69.52 Malignant neoplasm of left lacrimal gland and duct

C69.60 Malignant neoplasm of unspecified orbit

C69.61 Malignant neoplasm of right orbit

C69.62 Malignant neoplasm of left orbit

C69.80 Malignant neoplasm of overlapping sites of unspecified eye and adnexa

C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa

C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa

C69.90 Malignant neoplasm of unspecified site of unspecified eye

C69.91 Malignant neoplasm of unspecified site of right eye

C69.92 Malignant neoplasm of unspecified site of left eye

C81.10 Nodular sclerosis Hodgkin lymphoma, unspecified site

C81.11 Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.12 Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes

C81.13 Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes

C81.14 Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.15 Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.16 Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes

C81.17 Nodular sclerosis Hodgkin lymphoma, spleen

C81.18 Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple sites

C81.19 Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites

C81.20 Mixed cellularity Hodgkin lymphoma, unspecified site

C81.21 Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.22 Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes

C81.23 Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes

C81.24 Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.25 Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.26 Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes

C81.27 Mixed cellularity Hodgkin lymphoma, spleen

C81.28 Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites

C81.29 Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites

C81.30 Lymphocyte depleted Hodgkin lymphoma, unspecified site

C81.31 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.32 Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes

C81.33 Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes

C81.34 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.35 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.36 Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes

C81.37 Lymphocyte depleted Hodgkin lymphoma, spleen

C81.38 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites

C81.39 Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites

C81.40 Lymphocyte-rich Hodgkin lymphoma, unspecified site

C81.41 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.42 Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes

C81.43 Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes

C81.44 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.45 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.46 Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes

C81.47 Lymphocyte-rich Hodgkin lymphoma, spleen

C81.48 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiple sites

C81.49 Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites

C81.70 Other Hodgkin lymphoma, unspecified site

C81.71 Other Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.72 Other Hodgkin lymphoma, intrathoracic lymph nodes

C81.73 Other Hodgkin lymphoma, intra-abdominal lymph nodes

C81.74 Other Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.75 Other Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.76 Other Hodgkin lymphoma, intrapelvic lymph nodes

C81.77 Other Hodgkin lymphoma, spleen

C81.78 Other Hodgkin lymphoma, lymph nodes of multiple sites

C81.79 Other Hodgkin lymphoma, extranodal and solid organ sites

PEMBROLIZUMAB (KEYTRUDA®) IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

C00.0 Malignant neoplasm of external upper lip

C00.1 Malignant neoplasm of external lower lip

C00.2 Malignant neoplasm of external lip, unspecified

C00.3 Malignant neoplasm of upper lip, inner aspect

C00.4 Malignant neoplasm of lower lip, inner aspect

C00.5 Malignant neoplasm of lip, unspecified, inner aspect

C00.6 Malignant neoplasm of commissure of lip, unspecified

C00.8 Malignant neoplasm of overlapping sites of lip

C00.9 Malignant neoplasm of lip, unspecified

C01 Malignant neoplasm of base of tongue

C02.0 Malignant neoplasm of dorsal surface of tongue

C02.1 Malignant neoplasm of border of tongue

C02.2 Malignant neoplasm of ventral surface of tongue

C02.3 Malignant neoplasm of anterior two-thirds of tongue, part unspecified

C02.4 Malignant neoplasm of lingual tonsil

C02.8 Malignant neoplasm of overlapping sites of tongue

C02.9 Malignant neoplasm of tongue, unspecified

C03.0 Malignant neoplasm of upper gum

C03.1 Malignant neoplasm of lower gum

C03.9 Malignant neoplasm of gum, unspecified

C04.0 Malignant neoplasm of anterior floor of mouth

C04.1 Malignant neoplasm of lateral floor of mouth

C04.8 Malignant neoplasm of overlapping sites of floor of mouth

C04.9 Malignant neoplasm of floor of mouth, unspecified

C05.0 Malignant neoplasm of hard palate

C05.1 Malignant neoplasm of soft palate

C05.2 Malignant neoplasm of uvula

C05.8 Malignant neoplasm of overlapping sites of palate

C05.9 Malignant neoplasm of palate, unspecified

C06.0 Malignant neoplasm of cheek mucosa

C06.1 Malignant neoplasm of vestibule of mouth

C06.2 Malignant neoplasm of retromolar area

C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth

C06.89 Malignant neoplasm of overlapping sites of other parts of mouth

C06.9 Malignant neoplasm of mouth, unspecified

C09.0 Malignant neoplasm of tonsillar fossa

C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior)

C09.8 Malignant neoplasm of overlapping sites of tonsil

C09.9 Malignant neoplasm of tonsil, unspecified

C10.0 Malignant neoplasm of vallecula

C10.1 Malignant neoplasm of anterior surface of epiglottis

C10.2 Malignant neoplasm of lateral wall of oropharynx

C10.3 Malignant neoplasm of posterior wall of oropharynx

C10.4 Malignant neoplasm of branchial cleft

C10.8 Malignant neoplasm of overlapping sites of oropharynx

C10.9 Malignant neoplasm of oropharynx, unspecified

C11.0 Malignant neoplasm of superior wall of nasopharynx

C11.1 Malignant neoplasm of posterior wall of nasopharynx

C11.2 Malignant neoplasm of lateral wall of nasopharynx

C11.3 Malignant neoplasm of anterior wall of nasopharynx

C11.8 Malignant neoplasm of overlapping sites of nasopharynx

C11.9 Malignant neoplasm of nasopharynx, unspecified

C12 Malignant neoplasm of pyriform sinus

C13.0 Malignant neoplasm of postcricoid region

C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect

C13.2 Malignant neoplasm of posterior wall of hypopharynx

C13.8 Malignant neoplasm of overlapping sites of hypopharynx

C13.9 Malignant neoplasm of hypopharynx, unspecified

C14.0 Malignant neoplasm of pharynx, unspecified

C14.2 Malignant neoplasm of Waldeyer's ring

C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx

C18.0 Malignant neoplasm of cecum

C18.1 Malignant neoplasm of appendix

C18.2 Malignant neoplasm of ascending colon

C18.3 Malignant neoplasm of hepatic flexure

C18.4 Malignant neoplasm of transverse colon

C18.5 Malignant neoplasm of splenic flexure

C18.6 Malignant neoplasm of descending colon

C18.7 Malignant neoplasm of sigmoid colon

C18.8 Malignant neoplasm of overlapping sites of colon

C18.9 Malignant neoplasm of colon, unspecified

C19 Malignant neoplasm of rectosigmoid junction

C20 Malignant neoplasm of rectum

C21.0 Malignant neoplasm of anus, unspecified

C21.1 Malignant neoplasm of anal canal

C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal

C31.0 Malignant neoplasm of maxillary sinus

C31.1 Malignant neoplasm of ethmoidal sinus

C31.2 Malignant neoplasm of frontal sinus

C31.3 Malignant neoplasm of sphenoid sinus

C31.8 Malignant neoplasm of overlapping sites of accessory sinuses

C31.9 Malignant neoplasm of accessory sinus, unspecified

C32.0 Malignant neoplasm of glottis

C32.1 Malignant neoplasm of supraglottis

C32.2 Malignant neoplasm of subglottis

C32.3 Malignant neoplasm of laryngeal cartilage

C32.8 Malignant neoplasm of overlapping sites of larynx

C32.9 Malignant neoplasm of larynx, unspecified

C33 Malignant neoplasm of trachea

C34.00 Malignant neoplasm of unspecified main bronchus

C34.01 Malignant neoplasm of right main bronchus

C34.02 Malignant neoplasm of left main bronchus

C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

C34.12 Malignant neoplasm of upper lobe, left bronchus or lung

C34.2 Malignant neoplasm of middle lobe, bronchus or lung

C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31 Malignant neoplasm of lower lobe, right bronchus or lung

C34.32 Malignant neoplasm of lower lobe, left bronchus or lung

C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung

C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91 Malignant neoplasm of unspecified part of right bronchus or lung

C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

C43.0 Malignant melanoma of lip

C43.10 Malignant melanoma of unspecified eyelid, including canthus

C43.111 Malignant melanoma of right upper eyelid, including canthus

C43.112 Malignant melanoma of right lower eyelid, including canthus

C43.121 Malignant melanoma of left upper eyelid, including canthus

C43.122 Malignant melanoma of left lower eyelid, including canthus

C43.20 Malignant melanoma of unspecified ear and external auricular canal

C43.21 Malignant melanoma of right ear and external auricular canal

C43.22 Malignant melanoma of left ear and external auricular canal

C43.30 Malignant melanoma of unspecified part of face

C43.31 Malignant melanoma of nose

C43.39 Malignant melanoma of other parts of face

C43.4 Malignant melanoma of scalp and neck

C43.51 Malignant melanoma of anal skin

C43.52 Malignant melanoma of skin of breast

C43.59 Malignant melanoma of other part of trunk

C43.60 Malignant melanoma of unspecified upper limb, including shoulder

C43.61 Malignant melanoma of right upper limb, including shoulder

C43.62 Malignant melanoma of left upper limb, including shoulder

C43.70 Malignant melanoma of unspecified lower limb, including hip

C43.71 Malignant melanoma of right lower limb, including hip

C43.72 Malignant melanoma of left lower limb, including hip

C43.8 Malignant melanoma of overlapping sites of skin

C43.9 Malignant melanoma of skin, unspecified

C44.42 Squamous cell carcinoma of skin of scalp and neck

C45.0 Mesothelioma of pleura

C4A.0 Merkel cell carcinoma of lip

C4A.10 Merkel cell carcinoma of unspecified eyelid, including canthus

C4A.111 Merkel cell carcinoma of right upper eyelid, including canthus

C4A.112 Merkel cell carcinoma of right lower eyelid, including canthus

C4A.121 Merkel cell carcinoma of left upper eyelid, including canthus

C4A.122 Merkel cell carcinoma of left lower eyelid, including canthus

C4A.20 Merkel cell carcinoma of unspecified ear and external auricular canal

C4A.21 Merkel cell carcinoma of right ear and external auricular canal

C4A.22 Merkel cell carcinoma of left ear and external auricular canal

C4A.30 Merkel cell carcinoma of unspecified part of face

C4A.31 Merkel cell carcinoma of nose

C4A.39 Merkel cell carcinoma of other parts of face

C4A.4 Merkel cell carcinoma of scalp and neck

C4A.51 Merkel cell carcinoma of anal skin

C4A.52 Merkel cell carcinoma of skin of breast

C4A.59 Merkel cell carcinoma of other part of trunk

C4A.60 Merkel cell carcinoma of unspecified upper limb, including shoulder

C4A.61 Merkel cell carcinoma of right upper limb, including shoulder

C4A.62 Merkel cell carcinoma of left upper limb, including shoulder

C4A.70 Merkel cell carcinoma of unspecified lower limb, including hip

C4A.71 Merkel cell carcinoma of right lower limb, including hip

C4A.72 Merkel cell carcinoma of left lower limb, including hip

C4A.8 Merkel cell carcinoma of overlapping sites

C4A.9 Merkel cell carcinoma, unspecified

C51.0 Malignant neoplasm of labium majus

C51.1 Malignant neoplasm of labium minus

C51.2 Malignant neoplasm of clitoris

C51.8 Malignant neoplasm of overlapping sites of vulva

C51.9 Malignant neoplasm of vulva, unspecified

C52 Malignant neoplasm of vagina

C57.7 Malignant neoplasm of other specified female genital organs

C57.8 Malignant neoplasm of overlapping sites of female genital organs

C57.9 Malignant neoplasm of female genital organ, unspecified

C60.0 Malignant neoplasm of prepuce

C60.1 Malignant neoplasm of glans penis

C60.2 Malignant neoplasm of body of penis

C60.8 Malignant neoplasm of overlapping sites of penis

C60.9 Malignant neoplasm of penis, unspecified

C61 Malignant neoplasm of prostate

C63.00 Malignant neoplasm of unspecified epididymis

C63.01 Malignant neoplasm of right epididymis

C63.02 Malignant neoplasm of left epididymis

C63.10 Malignant neoplasm of unspecified spermatic cord

C63.11 Malignant neoplasm of right spermatic cord

C63.12 Malignant neoplasm of left spermatic cord

C63.2 Malignant neoplasm of scrotum

C63.7 Malignant neoplasm of other specified male genital organs

C63.8 Malignant neoplasm of overlapping sites of male genital organs

C63.9 Malignant neoplasm of male genital organ, unspecified

C65.1 Malignant neoplasm of right renal pelvis

C65.2 Malignant neoplasm of left renal pelvis

C65.9 Malignant neoplasm of unspecified renal pelvis

C66.1 Malignant neoplasm of right ureter

C66.2 Malignant neoplasm of left ureter

C66.9 Malignant neoplasm of unspecified ureter

C67.0 Malignant neoplasm of trigone of bladder

C67.1 Malignant neoplasm of dome of bladder

C67.2 Malignant neoplasm of lateral wall of bladder

C67.3 Malignant neoplasm of anterior wall of bladder

C67.4 Malignant neoplasm of posterior wall of bladder

C67.5 Malignant neoplasm of bladder neck

C67.6 Malignant neoplasm of ureteric orifice

C67.7 Malignant neoplasm of urachus

C67.8 Malignant neoplasm of overlapping sites of bladder

C67.9 Malignant neoplasm of bladder, unspecified

C68.0 Malignant neoplasm of urethra

C68.1 Malignant neoplasm of paraurethral glands

C68.8 Malignant neoplasm of overlapping sites of urinary organs

C68.9 Malignant neoplasm of urinary organ, unspecified

C69.00 Malignant neoplasm of unspecified conjunctiva

C69.01 Malignant neoplasm of right conjunctiva

C69.02 Malignant neoplasm of left conjunctiva

C69.10 Malignant neoplasm of unspecified cornea

C69.11 Malignant neoplasm of right cornea

C69.12 Malignant neoplasm of left cornea

C69.20 Malignant neoplasm of unspecified retina

C69.21 Malignant neoplasm of right retina

C69.22 Malignant neoplasm of left retina

C69.30 Malignant neoplasm of unspecified choroid

C69.31 Malignant neoplasm of right choroid

C69.32 Malignant neoplasm of left choroid

C69.40 Malignant neoplasm of unspecified ciliary body

C69.41 Malignant neoplasm of right ciliary body

C69.42 Malignant neoplasm of left ciliary body

C69.50 Malignant neoplasm of unspecified lacrimal gland and duct

C69.51 Malignant neoplasm of right lacrimal gland and duct

C69.52 Malignant neoplasm of left lacrimal gland and duct

C69.60 Malignant neoplasm of unspecified orbit

C69.61 Malignant neoplasm of right orbit

C69.62 Malignant neoplasm of left orbit

C69.80 Malignant neoplasm of overlapping sites of unspecified eye and adnexa

C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa

C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa

C69.90 Malignant neoplasm of unspecified site of unspecified eye

C69.91 Malignant neoplasm of unspecified site of right eye

C69.92 Malignant neoplasm of unspecified site of left eye

C7B.1 Secondary Merkel cell carcinoma

C81.10 Nodular sclerosis Hodgkin lymphoma, unspecified site

C81.11 Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.12 Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes

C81.13 Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes

C81.14 Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.15 Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.16 Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes

C81.17 Nodular sclerosis Hodgkin lymphoma, spleen

C81.18 Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple sites

C81.19 Nodular sclerosis Hodgkin lymphoma, extranodal and solid organ sites

C81.20 Mixed cellularity Hodgkin lymphoma, unspecified site

C81.21 Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.22 Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes

C81.23 Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes

C81.24 Mixed cellularity Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.25 Mixed cellularity Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.26 Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes

C81.27 Mixed cellularity Hodgkin lymphoma, spleen

C81.28 Mixed cellularity Hodgkin lymphoma, lymph nodes of multiple sites

C81.29 Mixed cellularity Hodgkin lymphoma, extranodal and solid organ sites

C81.30 Lymphocyte depleted Hodgkin lymphoma, unspecified site

C81.31 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.32 Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes

C81.33 Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes

C81.34 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.35 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.36 Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes

C81.37 Lymphocyte depleted Hodgkin lymphoma, spleen

C81.38 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of multiple sites

C81.39 Lymphocyte depleted Hodgkin lymphoma, extranodal and solid organ sites

C81.40 Lymphocyte-rich Hodgkin lymphoma, unspecified site

C81.41 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.42 Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes

C81.43 Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes

C81.44 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.45 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.46 Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes

C81.47 Lymphocyte-rich Hodgkin lymphoma, spleen

C81.48 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of multiple sites

C81.49 Lymphocyte-rich Hodgkin lymphoma, extranodal and solid organ sites

C81.70 Other Hodgkin lymphoma, unspecified site

C81.71 Other Hodgkin lymphoma, lymph nodes of head, face, and neck

C81.72 Other Hodgkin lymphoma, intrathoracic lymph nodes

C81.73 Other Hodgkin lymphoma, intra-abdominal lymph nodes

C81.74 Other Hodgkin lymphoma, lymph nodes of axilla and upper limb

C81.75 Other Hodgkin lymphoma, lymph nodes of inguinal region and lower limb

C81.76 Other Hodgkin lymphoma, intrapelvic lymph nodes

C81.77 Other Hodgkin lymphoma, spleen

C81.78 Other Hodgkin lymphoma, lymph nodes of multiple sites

C81.79 Other Hodgkin lymphoma, extranodal and solid organ sites

AVELUMAB (BAVENCIO®) IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

C4A.0 Merkel cell carcinoma of lip

C4A.10 Merkel cell carcinoma of unspecified eyelid, including canthus

C4A.111 Merkel cell carcinoma of right upper eyelid, including canthus

C4A.112 Merkel cell carcinoma of right lower eyelid, including canthus

C4A.121 Merkel cell carcinoma of left upper eyelid, including canthus

C4A.122 Merkel cell carcinoma of left lower eyelid, including canthus

C4A.20 Merkel cell carcinoma of unspecified ear and external auricular canal

C4A.21 Merkel cell carcinoma of right ear and external auricular canal

C4A.22 Merkel cell carcinoma of left ear and external auricular canal

C4A.30 Merkel cell carcinoma of unspecified part of face

C4A.31 Merkel cell carcinoma of nose

C4A.39 Merkel cell carcinoma of other parts of face

C4A.4 Merkel cell carcinoma of scalp and neck

C4A.51 Merkel cell carcinoma of anal skin

C4A.52 Merkel cell carcinoma of skin of breast

C4A.59 Merkel cell carcinoma of other part of trunk

C4A.60 Merkel cell carcinoma of unspecified upper limb, including shoulder

C4A.61 Merkel cell carcinoma of right upper limb, including shoulder

C4A.62 Merkel cell carcinoma of left upper limb, including shoulder

C4A.70 Merkel cell carcinoma of unspecified lower limb, including hip

C4A.71 Merkel cell carcinoma of right lower limb, including hip

C4A.72 Merkel cell carcinoma of left lower limb, including hip

C4A.8 Merkel cell carcinoma of overlapping sites

C4A.9 Merkel cell carcinoma, unspecified

C7B.1 Secondary Merkel cell carcinoma

C61 Malignant neoplasm of prostate

C65.1 Malignant neoplasm of right renal pelvis

C65.2 Malignant neoplasm of left renal pelvis

C65.9 Malignant neoplasm of unspecified renal pelvis

C66.1 Malignant neoplasm of right ureter

C66.2 Malignant neoplasm of left ureter

C66.9 Malignant neoplasm of unspecified ureter

C67.0 Malignant neoplasm of trigone of bladder

C67.1 Malignant neoplasm of dome of bladder

C67.2 Malignant neoplasm of lateral wall of bladder

C67.3 Malignant neoplasm of anterior wall of bladder

C67.4 Malignant neoplasm of posterior wall of bladder

C67.5 Malignant neoplasm of bladder neck

C67.6 Malignant neoplasm of ureteric orifice

C67.7 Malignant neoplasm of urachus

C67.8 Malignant neoplasm of overlapping sites of bladder

C67.9 Malignant neoplasm of bladder, unspecified

C68.0 Malignant neoplasm of urethra

C68.1 Malignant neoplasm of paraurethral glands

C68.8 Malignant neoplasm of overlapping sites of urinary organs

C68.9 Malignant neoplasm of urinary organ, unspecified

DURVALUMAB (IMFINZI) IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

C61 Malignant neoplasm of prostate

C65.1 Malignant neoplasm of right renal pelvis

C65.2 Malignant neoplasm of left renal pelvis

C65.9 Malignant neoplasm of unspecified renal pelvis

C66.1 Malignant neoplasm of right ureter

C66.2 Malignant neoplasm of left ureter

C66.9 Malignant neoplasm of unspecified ureter

C67.0 Malignant neoplasm of trigone of bladder

C67.1 Malignant neoplasm of dome of bladder

C67.2 Malignant neoplasm of lateral wall of bladder

C67.3 Malignant neoplasm of anterior wall of bladder

C67.4 Malignant neoplasm of posterior wall of bladder

C67.5 Malignant neoplasm of bladder neck

C67.6 Malignant neoplasm of ureteric orifice

C67.7 Malignant neoplasm of urachus

C67.8 Malignant neoplasm of overlapping sites of bladder

C67.9 Malignant neoplasm of bladder, unspecified

C68.0 Malignant neoplasm of urethra

C68.1 Malignant neoplasm of paraurethral glands

C68.8 Malignant neoplasm of overlapping sites of urinary organs

C68.9 Malignant neoplasm of urinary organ, unspecified



Version Effective Date: 01/01/2019
Version Issued Date: 01/03/2019
Version Reissued Date: N/A

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