Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Infliximab or an infliximab biosimilar may be considered medically necessary when an individual meets the criteria for
ANY ONE
of the following indications:
- Ankylosing Spondylitis (AS), Crohn's Disease (CD), Plaque Psoriasis (PsO), Psoriatic Arthritis (PsA), Rheumatoid arthritis (RA), or Ulcerative Colitis (UC)
-
The individual must meet Food and Drug Administration (FDA)-approved label for use (e.g., use outside of studied population will be considered investigational);
or
- Other
-
The individual has another FDA labeled indication for the requested agent and must meet FDA-approved label for use (e.g., use outside of studied population will be considered investigational);
or
- The individual has another indication supported in compendia for the requested agent and route of administration
The use of infliximab or an infliximab biosimilar for any other indication is considered experimental/investigational, and therefore, non-covered. Scientific evidence does not support its use for any other indications.
Procedure Codes
