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MA08.127d
A
MA08.127d
ICD-10 Codes and Narratives
Atezolizumab (Tecentriq®) and Atezolizumab with Hyaluronidase-tqjs (Tecentriq Hybreza TM)


ATEZOLIZUMAB (TECENTRIQ®AND ATEZOLIZUMAB WITH HYALOURONIDASE-TQJS (TECENTRIQ HYBREZA​TM) ARE MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

C22.0Liver cell carcinoma
C22.8Malignant neoplasm of liver, primary, unspecified as to type
C22.9Malignant neoplasm of liver, not specified as primary or secondary
C33 Malignant neoplasm of trachea
C34.01Malignant neoplasm of right main bronchus​
C34.02Malignant neoplasm of left main bronchus
C34.11Malignant neoplasm of upper lobe, right bronchus or lung
C34.12Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.31Malignant neoplasm of lower lobe, right bronchus or lung
C34.32Malignant neoplasm of lower lobe, left bronchus or lung
C34.81Malignant neoplasm of overlapping sites of right bronchus and lung​
C34.82Malignant neoplasm of overlapping sites of left bronchus and lung
C34.91Malignant 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
C43.111Malignant melanoma of right upper eyelid, including canthus
C43.112Malignant melanoma of right lower eyelid, including canthus
C43.121Malignant melanoma of left upper eyelid, including canthus
C43.122Malignant melanoma of left lower eyelid, including canthus
C43.21Malignant melanoma of right ear and external auricular canal
C43.22Malignant melanoma of left ear and external auricular canal
C43.30Malignant melanoma of unspecified part of face
C43.31Malignant melanoma of nose
C43.39Malignant melanoma of other parts of face
C43.4 Malignant melanoma of scalp and neck
C43.51Malignant melanoma of anal skin
C43.52Malignant melanoma of skin of breast
C43.59Malignant melanoma of other part of trunk
C43.61Malignant melanoma of right upper limb, including shoulder
C43.62Malignant melanoma of left upper limb, including shoulder
C43.71Malignant melanoma of right lower limb, including hip
C43.72Malignant melanoma of left lower limb, including hip
C43.8Malignant melanoma of overlapping sites of skin
C43.9Malignant melanoma of skin, unspecified ​
C45.1Mesothelioma of peritoneum
C45.2Mesothelioma of pericardium
C45.7Mesothelioma of other sites
C45.9Mesothelioma, unspecified
C49.0Malignant neoplasm of connective and soft tissue of head, face and neck
C49.11Malignant neoplasm of connective and soft tissue of right upper limb, including shoulder
C49.12Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder
C49.21Malignant neoplasm of connective and soft tissue of right lower limb, including hip
C49.22Malignant neoplasm of connective and soft tissue of left lower limb, including hip
C49.3Malignant neoplasm of connective and soft tissue of thorax
C49.4Malignant neoplasm of connective and soft tissue of abdomen
C49.5Malignant neoplasm of connective and soft tissue of pelvis
C49.6Malignant neoplasm of connective and soft tissue of trunk, unspecified
C49.8Malignant neoplasm of overlapping sites of connective and soft tissue
C49.9Malignant neoplasm of connective and soft tissue, unspecified
C53.0Malignant neoplasm of endocervix
C53.1Malignant neoplasm of exocervix
C53.8Malignant neoplasm of overlapping sites of cervix uteri
C53.9Malignant neoplasm of cervix uteri, unspecified​
C78.01Secondary malignant neoplasm of right lung
C78.02Secondary malignant neoplasm of left lung
C79.31Secondary malignant neoplasm of brain
C79.51Secondary malignant neoplasm of bone
C79.52Secondary malignant neoplasm of bone marrow
C7A.1Malignant poorly differentiated neuroendocrine tumors



01/01/2025
01/02/2025
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Medical Policy Bulletin
Medicare Advantage
e7ed6dae-04e7-4729-ab35-e88ea52c6e85
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