Medical Drug Criteria (MDC)

Policy Num: M5.001.008
Policy Name: Simponi ARIA® (golimumab)
Policy ID: [M5.001.008] [Ac / Mg / M+ / P+] [PI]

Last Review: May 10, 2024
Next Review: May 20, 2025

Related Policies:

Simponi ARIA® (golimumab)

Popultation Reference No.	Populations
1	Individuals: With Rheumatoid Arthritis
2	Individuals: With Psoriatic Arthritis
3	Individuals: With Ankylosing Spondylitis
4	Individuals: With Polyarticular Juvenile Idiopathic Arthritis

Summary

Golimumab is in a class of drugs called biologics. Golimumab is a treatment for adults with moderate to severe rheumatoid arthritis, active psoriatic arthritis, or active ankylosing spondylitis. It is injected under the skin to reduce signs and symptoms of rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis, such as joint swelling, pain, fatigue, and length of morning stiffness. Golimumab is commonly known as Simponi®. It can also be given as an infusion.

Policy Statements

Simponi ARIA® (golimumab) may be considered medically necessary in patients is at least 18 years of age, unless otherwise specified; for the following diagnosis:

Rheumatoid Arthritis
Psoriatic Arthritis
Ankylosing Spondylitis
Polyarticular Juvenile Idiopathic Arthritis

Policy Guidelines

Coverage is provided in the following conditions:
• Patient is at least 18 years of age, unless otherwise specified; AND
• Patient has been evaluated and screened for the presence hepatitis B virus (HBV) prior to initiating treatment; AND
• Physician has assessed baseline disease severity utilizing an objective measure/tool; AND

Universal Criteria¹

Patient has been evaluated and screened for the presence of latent tuberculosis (TB) infection prior to initiating treatment and will receive ongoing monitoring for presence of TB during treatment; AND
Patient does not have an active infection, including clinically important localized infections; AND
Patient will not receive live vaccines during therapy; AND
Patient is not on concurrent treatment with another TNF inhibitor, biologic response modifier or other non-biologic agent (i.e., apremilast, tofacitinib, baricitinib); AND

Rheumatoid Arthritis (RA) ^1-4,9-11,17

Must be prescribed by, or in consultation with, a specialist in rheumatology; AND
Documented moderate to severe active disease; AND
Patient has had at least a 3 month trial and failed of previous therapy with ONE oral disease modifying anti-rheumatic agent (DMARD) such as methotrexate, azathioprine, auranofin, hydroxychloroquine, penicillamine, sulfasalazine, leflunomide, etc.; AND
Prescribed in combination with methotrexate unless contraindicated

Psoriatic Arthritis (PsA) ^5,6,8,18

Patient is at least 2 years of age; AND
Must be prescribed by, or in consultation with, a specialist in dermatology or rheumatology; AND
Documented moderate to severe active disease; AND
- For patients with predominantly axial disease OR active enthesitis, a trial and failure of at least a 4 week trial of ONE non-steroidal anti-inflammatory agents (NSAIDs), unless use is contraindicated; OR
- For patients with peripheral arthritis or dactylitis, a trial and failure of at least a 3 month trial of ONE oral disease-modifying anti-rheumatic agent (DMARD) such as methotrexate, azathioprine, sulfasalazine, or hydroxychloroquine

Ankylosing Spondylitis (AS) ^7,12,19

Must be prescribed by, or in consultation with, a specialist in rheumatology; AND
Documented active disease; AND
Patient had an adequate trial and failure of at least TWO (2) non-steroidal anti-inflammatory agents (NSAIDs) over 4 weeks (in total), unless use is contraindicated

Polyarticular Juvenile Idiopathic Arthritis (pJIA) ¹⁴

Patient is at least 2 years of age; AND
Documented moderate to severe active polyarticular disease; AND
May be used alone or in combination with methotrexate; AND
Patient has had at least a 1-month trial and failure (unless contraindicated or intolerant) of previous therapy with either oral non-steroidal anti-inflammatory drugs (NSAIDs) OR an oral disease-modifying anti-rheumatic agent (DMARD) (e.g., methotrexate, leflunomide, sulfasalazine, etc.)

Renewal Criteria ^1,2,3,8

Coverage can be renewed based upon the following criteria:

Patient continues to meet universal and other indication-specific relevant criteria such as concomitant therapy requirements (not including prerequisite therapy), performance status, etc. identified in section III; AND
Absence of unacceptable toxicity from the drug. Examples of unacceptable toxicity include the following: serious infections, cardiotoxicity/heart failure, malignancy, demyelinating disorders, lupus-like syndrome, severe hypersensitivity reactions, severe hematologic cytopenias (e.g., pancytopenia, leukopenia, neutropenia, thrombocytopenia), etc.; AND

Rheumatoid Arthritis 9-11

Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts, reduction of C-reactive protein, improvement of patient global assessment, and/or an improvement on a disease activity scoring tool [e.g. an improvement on a composite scoring index such as Disease Activity Score-28 (DAS28) of 1.2 points or more or a ≥20% improvement on the American College of Rheumatology-20 (ACR20) criteria].

Psoriatic Arthritis 8

Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts and/or an improvement on a disease activity scoring tool [e.g. defined as an improvement in at least 2 of the 4 Psoriatic Arthritis Response Criteria (PsARC), 1 of which must be joint tenderness or swelling score, with no worsening in any of the 4 criteria].

Ankylosing Spondylitis 7

Disease response as indicated by improvement in signs and symptoms compared to baseline such as total back pain, physical function, morning stiffness, and/or an improvement on a disease activity scoring tool [e.g. ≥ 1.1 improvement on the Ankylosing Spondylitis Disease Activity Score (ASDAS) or an improvement of ≥ 2 on the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)].

Polyarticular Juvenile Idiopathic Arthritis (pJIA) 15,16

Disease response as indicated by improvement in signs and symptoms compared to baseline such as the number of tender and swollen joint counts, reduction of C-reactive protein, improvement of patient global assessment, and/or an improvement on a disease activity scoring tool [e.g., an improvement on a composite scoring index such as Juvenile Arthritis Disease Activity Score (JADAS) or the American College of Rheumatology (ACR) Pediatric (ACR-Pedi 30) of at least 30% improvement from baseline in three of six variables].

DOSAGE/ADMINISTRATION

Rheumatoid Arthritis, Ankylosing Spondylitis: Administer a 2 mg/kg intravenous infusion at weeks 0 and 4, then every 8 weeks thereafter.

Psoriatic Arthritis: Adult: Administer a 2 mg/kg intravenous infusion at weeks 0 and 4, then every 8 weeks thereafter. Pediatric: Administer an 80 mg/m2 intravenous infusion at weeks 0 and 4, and every 8 weeks thereafter.

Polyarticular Juvenile Idiopathic Arthritis: Administer an 80 mg/m2 intravenous infusion at weeks 0 and 4, and every 8 weeks thereafter.

REQUIRED MEDICAL INFORMATION

As established above.

EXCLUSION CRITERIA

None

BENEFIT APPLICATION

As established in policy. Initial coverage will be for three months and is eligible for renewal for six months.

Medicare coverage criteria

There was no LCD, NDC identified for PR region.

Medicare coverage for outpatient (Part B) drugs is outlined in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologicals. In addition, National Coverage Determination (NCD), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs) may exist and compliance with these policies is required where applicable. They can be found at: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx. Additional indications may be covered at the discretion of the health plan.

THER CRITERIA

References

1. Simponi ARIA [package insert]. Horsham, PA; Janssen Biotech Inc; February 2021. Accessed July 2021.

2. Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2015 Nov 6. doi: 10.1002/acr.22783.

3. Weinblatt ME, Bingham CO 3rd, Mendelsohn AM, et al. Intravenous golimumab is effective in patients with active rheumatoid arthritis despite methotrexate therapy with responses as early as week 2: results of the phase 3, randomised, multicentre, double-blind, placebocontrolled GO-FURTHER trial. Ann Rheum Dis. 2013 Mar;72(3):381-9. doi: 10.1136/annrheumdis-2012-201411. Epub 2012 Jun 1.

4. Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017 Mar 6. pii: annrheumdis-2016-210715.

5. Gottlieb A, Korman NJ, Gordon KB, Feldman SR, Lebwohl M, Koo JY, Van Voorhees AS, Elmets CA, Leonardi CL, Beutner KR, Bhushan R, Menter A. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol 2008 May; 58(5):851-64.

6. Ramiro S, Smolen JS, Landewé R, et al. Pharmacological treatment of psoriatic arthritis: a systematic literature review for the 2015 update of the EULAR recommendations for the management of psoriatic arthritis. Ann Rheum Dis 2016;75:490-498 doi:10.1136/annrheumdis-2015-208466

7. Van Der Heijde D, Ramiro S, Landewe R, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis doi:10.1136/annrheumdis-2016-210770

8. National Institute for Health and Care Excellence. NICE 2017. Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs Published 24 May 2017. Technology Appraisal Guidance [TA445]. https://www.nice.org.uk/guidance/TA445/chapter/1-Recommendations. Accessed August 2017.

9. National Institute for Health and Care Excellence. NICE 2009. Rheumatoid Arthritis in Adults: Management. Published 25 February 2009. Clinical Guideline [CG79]. https://www.nice.org.uk/guidance/cg79/resources/rheumatoid-arthritis-in-adultsmanagement-pdf-975636823525.

10. National Institute for Health and Care Excellence. NICE 2010. Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after failure of a TNF inhibitor. Published 10 October 2012. Clinical Guideline [TA195]. https://www.nice.org.uk/guidance/ta195/resources/adalimumab-etanercept-infliximabrituximab-and-abatacept-for-the-treatment-of-rheumatoid-arthritis-after-the-failure-of-atnf-inhibitor-pdf-82598558287813.

11. Ward MM, Guthri LC, Alba MI. Rheumatoid Arthritis Response Criteria And PatientReported Improvement in Arthritis Activity: Is an ACR20 Response Meaningful to Patients”. Arthritis Rheumatol. 2014 Sep; 66(9): 2339–2343. doi: 10.1002/art.38705

12. Ward M, Deodhar A, Gensler L, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. 2019 Aug; Arthritis Care Res. doi: 10.1002/acr.24025.

13. Fahrenbruch R, Kintzel P, Bott AM, et al. Dose Rounding of Biologic and Cytotoxic Anticancer Agents: A Position Statement of the Hematology/Oncology Pharmacy Association. J Oncol Pract. 2018 Mar;14(3):e130-e136.

14. Ringold S, Angeles‐Han ST, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Non-Systemic Polyarthritis, Sacroiliitis, and Enthesitis. Arthritis Care & Research, Vol. 71, No. 6, June 2019, pp 717–734 DOI 10.1002/acr.23870.

15. Ringold S, Bittner R, Neggi T, et al. Performance of rheumatoid arthritis disease activity measures and juvenile arthritis disease activity scores in polyarticular-course juvenile idiopathic arthritis: Analysis of their ability to classify the American College of Rheumatology pediatric measures of response and the preliminary criteria for flare and inactive disease. Arthritis Care Res (Hoboken). 2010 Aug;62(8):1095-102.

16. Consolaro A, Giancane G, Schiappapietra B, et al. Clinical outcome measures in juvenile idiopathic arthritis. Pediatric Rheumatology 18 April 2016 14:23.

17. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2021 Jun 8. doi: 10.1002/acr.24596.

18. Gossec L, Baraliakos X, Kerschbaumer A, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis. 2020 Jun;79(6):700-712. doi: 10.1136/annrheumdis-2020-217159.

19. Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019 Oct;71(10):1599-1613. doi: 10.1002/art.41042.

Codes

CODES	NUMBER	DESCRIPTION
HCPCS	J1602	Injection, golimumab, 1 mg, for intravenous use
ICD-10-CM	L40.50	Arthropathic psoriasis, unspecified
	L40.51	Distal interphalangeal psoriatic arthropathy
	L40.52	Psoriatic arthritis mutilans
	L40.53	Psoriatic spondylitis
	L40.59	Other psoriatic arthropathy
	M05.10	Rheumatoid lung disease with rheumatoid arthritis of unspecified site
	M05.111	Rheumatoid lung disease with rheumatoid arthritis of right shoulder
	M05.112	Rheumatoid lung disease with rheumatoid arthritis of left shoulder
	M05.119	Rheumatoid lung disease with rheumatoid arthritis of unspecified shoulder
	M05.121	Rheumatoid lung disease with rheumatoid arthritis of right elbow
	M05.122	Rheumatoid lung disease with rheumatoid arthritis of left elbow
	M05.129	Rheumatoid lung disease with rheumatoid arthritis of unspecified elbow
	M05.131	Rheumatoid lung disease with rheumatoid arthritis of right wrist
	M05.132	Rheumatoid lung disease with rheumatoid arthritis of left wrist
	M05.139	Rheumatoid lung disease with rheumatoid arthritis of unspecified wrist
	M05.141	Rheumatoid lung disease with rheumatoid arthritis of right hand
	M05.142	Rheumatoid lung disease with rheumatoid arthritis of left hand
	M05.149	Rheumatoid lung disease with rheumatoid arthritis of unspecified hand
	M05.151	Rheumatoid lung disease with rheumatoid arthritis of right hip
	M05.152	Rheumatoid lung disease with rheumatoid arthritis of left hip
	M05.159	Rheumatoid lung disease with rheumatoid arthritis of unspecified hip
	M05.161	Rheumatoid lung disease with rheumatoid arthritis of right knee
	M05.162	Rheumatoid lung disease with rheumatoid arthritis of left knee
	M05.169	Rheumatoid lung disease with rheumatoid arthritis of unspecified knee
	M05.171	Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot
	M05.172	Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot
	M05.179	Rheumatoid lung disease with rheumatoid arthritis of unspecified ankle and foot

	M05.19	Rheumatoid lung disease with rheumatoid arthritis of multiple sites
	M05.20	Rheumatoid vasculitis with rheumatoid arthritis of unspecified site
	M05.211	Rheumatoid vasculitis with rheumatoid arthritis of right shoulder
	M05.212	Rheumatoid vasculitis with rheumatoid arthritis of left shoulder
	M05.219	Rheumatoid vasculitis with rheumatoid arthritis of unspecified shoulder
	M05.221	Rheumatoid vasculitis with rheumatoid arthritis of right elbow
	M05.222	Rheumatoid vasculitis with rheumatoid arthritis of left elbow
	M05.229	Rheumatoid vasculitis with rheumatoid arthritis of unspecified elbow
	M05.231	Rheumatoid vasculitis with rheumatoid arthritis of right wrist
	M05.232	Rheumatoid vasculitis with rheumatoid arthritis of left wrist
	M05.239	Rheumatoid vasculitis with rheumatoid arthritis of unspecified wrist
	M05.241	Rheumatoid vasculitis with rheumatoid arthritis of right hand
	M05.242	Rheumatoid vasculitis with rheumatoid arthritis of left hand
	M05.249	Rheumatoid vasculitis with rheumatoid arthritis of unspecified hand
	M05.251	Rheumatoid vasculitis with rheumatoid arthritis of right hip
	M05.252	Rheumatoid vasculitis with rheumatoid arthritis of left hip
	M05.259	Rheumatoid vasculitis with rheumatoid arthritis of unspecified hip
	M05.261	Rheumatoid vasculitis with rheumatoid arthritis of right knee
	M05.262	Rheumatoid vasculitis with rheumatoid arthritis of left knee
	M05.269	Rheumatoid vasculitis with rheumatoid arthritis of unspecified knee
	M05.271	Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot
	M05.272	Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot
	M05.279	Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot
	M05.29	Rheumatoid vasculitis with rheumatoid arthritis of multiple sites
	M05.30	Rheumatoid heart disease with rheumatoid arthritis of unspecified site
	M05.311	Rheumatoid heart disease with rheumatoid arthritis of right shoulder
	M05.312	Rheumatoid heart disease with rheumatoid arthritis of left shoulder
	M05.319	Rheumatoid heart disease with rheumatoid arthritis of unspecified shoulder
	M05.321	Rheumatoid heart disease with rheumatoid arthritis of right elbow
	M05.322	Rheumatoid heart disease with rheumatoid arthritis of left elbow
	M05.329	Rheumatoid heart disease with rheumatoid arthritis of unspecified elbow
	M05.331	Rheumatoid heart disease with rheumatoid arthritis of right wrist
	M05.332	Rheumatoid heart disease with rheumatoid arthritis of left wrist
	M05.339	Rheumatoid heart disease with rheumatoid arthritis of unspecified wrist
	M05.341	Rheumatoid heart disease with rheumatoid arthritis of right hand
	M05.342	Rheumatoid heart disease with rheumatoid arthritis of left hand
	M05.349	Rheumatoid heart disease with rheumatoid arthritis of unspecified hand

	M05.351	Rheumatoid heart disease with rheumatoid arthritis of right hip
	M05.352	Rheumatoid heart disease with rheumatoid arthritis of left hip
	M05.359	Rheumatoid heart disease with rheumatoid arthritis of unspecified hip
	M05.361	Rheumatoid heart disease with rheumatoid arthritis of right knee
	M05.362	Rheumatoid heart disease with rheumatoid arthritis of left knee
	M05.369	Rheumatoid heart disease with rheumatoid arthritis of unspecified knee
	M05.371	Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot
	M05.372	Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot
	M05.379	Rheumatoid heart disease with rheumatoid arthritis of unspecified ankle and foot
	M05.39	Rheumatoid heart disease with rheumatoid arthritis of multiple sites
	M05.40	Rheumatoid myopathy with rheumatoid arthritis of unspecified site
	M05.411	Rheumatoid myopathy with rheumatoid arthritis of right shoulder
	M05.412	Rheumatoid myopathy with rheumatoid arthritis of left shoulder
	M05.419	Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder
	M05.421	Rheumatoid myopathy with rheumatoid arthritis of right elbow
	M05.422	Rheumatoid myopathy with rheumatoid arthritis of left elbow
	M05.429	Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow
	M05.431	Rheumatoid myopathy with rheumatoid arthritis of right wrist
	M05.432	Rheumatoid myopathy with rheumatoid arthritis of left wrist
	M05.439	Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist
	M05.441	Rheumatoid myopathy with rheumatoid arthritis of right hand
	M05.442	Rheumatoid myopathy with rheumatoid arthritis of left hand
	M05.449	Rheumatoid myopathy with rheumatoid arthritis of unspecified hand
	M05.451	Rheumatoid myopathy with rheumatoid arthritis of right hip
	M05.452	Rheumatoid myopathy with rheumatoid arthritis of left hip
	M05.459	Rheumatoid myopathy with rheumatoid arthritis of unspecified hip
	M05.461	Rheumatoid myopathy with rheumatoid arthritis of right knee
	M05.462	Rheumatoid myopathy with rheumatoid arthritis of left knee
	M05.469	Rheumatoid myopathy with rheumatoid arthritis of unspecified knee
	M05.471	Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
	M05.472	Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
	M05.479	Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot
	M05.49	Rheumatoid myopathy with rheumatoid arthritis of multiple sites
	M05.50	Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site
	M05.511	Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
	M05.512	Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
	M05.519	Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder

	M05.521	Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
	M05.522	Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
	M05.529	Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow
	M05.531	Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
	M05.532	Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
	M05.539	Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist
	M05.541	Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
	M05.542	Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
	M05.549	Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand
	M05.551	Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
	M05.552	Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
	M05.559	Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip
	M05.561	Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
	M05.562	Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
	M05.569	Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee
	M05.571	Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
	M05.572	Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
	M05.579	Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot
	M05.59	Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
	M05.60	Rheumatoid arthritis of unspecified site with involvement of other organs and systems
	M05.611	Rheumatoid arthritis of right shoulder with involvement of other organs and systems
	M05.612	Rheumatoid arthritis of left shoulder with involvement of other organs and systems
	M05.619	Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems
	M05.621	Rheumatoid arthritis of right elbow with involvement of other organs and systems
	M05.622	Rheumatoid arthritis of left elbow with involvement of other organs and systems
	M05.629	Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems
	M05.631	Rheumatoid arthritis of right wrist with involvement of other organs and systems
	M05.632	Rheumatoid arthritis of left wrist with involvement of other organs and systems
	M05.639	Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems
	M05.641	Rheumatoid arthritis of right hand with involvement of other organs and systems
	M05.642	Rheumatoid arthritis of left hand with involvement of other organs and systems
	M05.649	Rheumatoid arthritis of unspecified hand with involvement of other organs and systems
	M05.651	Rheumatoid arthritis of right hip with involvement of other organs and systems
	M05.652	Rheumatoid arthritis of left hip with involvement of other organs and systems
	M05.659	Rheumatoid arthritis of unspecified hip with involvement of other organs and systems
	M05.661	Rheumatoid arthritis of right knee with involvement of other organs and systems
	M05.662	Rheumatoid arthritis of left knee with involvement of other organs and systems

	M05.669	Rheumatoid arthritis of unspecified knee with involvement of other organs and systems
	M05.671	Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems
	M05.672	Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems
	M05.679	Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems
	M05.69	Rheumatoid arthritis of multiple sites with involvement of other organs and systems
	M05.7A	Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement
	M05.711	Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement
	M05.712	Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement
	M05.719	Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement
	M05.721	Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement
	M05.722	Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement
	M05.729	Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement
	M05.731	Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement
	M05.732	Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement
	M05.739	Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement
	M05.741	Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement
	M05.742	Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement
	M05.749	Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement
	M05.751	Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement
	M05.752	Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement
	M05.759	Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement
	M05.761	Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement
	M05.762	Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement
	M05.769	Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement
	M05.771	Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement
	M05.772	Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
	M05.779	Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement
	M05.79	Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
	M05.8A	Other rheumatoid arthritis with rheumatoid factor of other specified site
	M05.811	Other rheumatoid arthritis with rheumatoid factor of right shoulder

	M05.812	Other rheumatoid arthritis with rheumatoid factor of left shoulder
	M05.819	Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder
	M05.821	Other rheumatoid arthritis with rheumatoid factor of right elbow
	M05.822	Other rheumatoid arthritis with rheumatoid factor of left elbow
	M05.829	Other rheumatoid arthritis with rheumatoid factor of unspecified elbow
	M05.831	Other rheumatoid arthritis with rheumatoid factor of right wrist
	M05.832	Other rheumatoid arthritis with rheumatoid factor of left wrist
	M05.839	Other rheumatoid arthritis with rheumatoid factor of unspecified wrist
	M05.841	Other rheumatoid arthritis with rheumatoid factor of right hand
	M05.842	Other rheumatoid arthritis with rheumatoid factor of left hand
	M05.849	Other rheumatoid arthritis with rheumatoid factor of unspecified hand
	M05.851	Other rheumatoid arthritis with rheumatoid factor of right hip
	M05.852	Other rheumatoid arthritis with rheumatoid factor of left hip
	M05.859	Other rheumatoid arthritis with rheumatoid factor of unspecified hip
	M05.861	Other rheumatoid arthritis with rheumatoid factor of right knee
	M05.862	Other rheumatoid arthritis with rheumatoid factor of left knee
	M05.869	Other rheumatoid arthritis with rheumatoid factor of unspecified knee
	M05.871	Other rheumatoid arthritis with rheumatoid factor of right ankle and foot
	M05.872	Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
	M05.879	Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot
	M05.89	Other rheumatoid arthritis with rheumatoid factor of multiple sites
	M05.9	Rheumatoid arthritis with rheumatoid factor, unspecified
	M06.0A	Rheumatoid arthritis without rheumatoid factor, other specified site
	M06.011	Rheumatoid arthritis without rheumatoid factor, right shoulder
	M06.012	Rheumatoid arthritis without rheumatoid factor, left shoulder
	M06.019	Rheumatoid arthritis without rheumatoid factor, unspecified shoulder
	M06.021	Rheumatoid arthritis without rheumatoid factor, right elbow
	M06.022	Rheumatoid arthritis without rheumatoid factor, left elbow
	M06.029	Rheumatoid arthritis without rheumatoid factor, unspecified elbow
	M06.031	Rheumatoid arthritis without rheumatoid factor, right wrist
	M06.032	Rheumatoid arthritis without rheumatoid factor, left wrist
	M06.039	Rheumatoid arthritis without rheumatoid factor, unspecified wrist
	M06.041	Rheumatoid arthritis without rheumatoid factor, right hand
	M06.042	Rheumatoid arthritis without rheumatoid factor, left hand
	M06.049	Rheumatoid arthritis without rheumatoid factor, unspecified hand
	M06.051	Rheumatoid arthritis without rheumatoid factor, right hip
	M06.052	Rheumatoid arthritis without rheumatoid factor, left hip

	M06.059	Rheumatoid arthritis without rheumatoid factor, unspecified hip
	M06.061	Rheumatoid arthritis without rheumatoid factor, right knee
	M06.062	Rheumatoid arthritis without rheumatoid factor, left knee
	M06.069	Rheumatoid arthritis without rheumatoid factor, unspecified knee
	M06.071	Rheumatoid arthritis without rheumatoid factor, right ankle and foot
	M06.072	Rheumatoid arthritis without rheumatoid factor, left ankle and foot
	M06.079	Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot
	M06.08	Rheumatoid arthritis without rheumatoid factor, vertebrae
	M06.09	Rheumatoid arthritis without rheumatoid factor, multiple sites
	M06.8A	Other specified rheumatoid arthritis, other specified site
	M06.811	Other specified rheumatoid arthritis, right shoulder
	M06.812	Other specified rheumatoid arthritis, left shoulder
	M06.819	Other specified rheumatoid arthritis, unspecified shoulder
	M06.821	Other specified rheumatoid arthritis, right elbow
	M06.822	Other specified rheumatoid arthritis, left elbow
	M06.829	Other specified rheumatoid arthritis, unspecified elbow
	M06.831	Other specified rheumatoid arthritis, right wrist
	M06.832	Other specified rheumatoid arthritis, left wrist
	M06.839	Other specified rheumatoid arthritis, unspecified wrist
	M06.841	Other specified rheumatoid arthritis, right hand
	M06.842	Other specified rheumatoid arthritis, left hand
	M06.849	Other specified rheumatoid arthritis, unspecified hand
	M06.851	Other specified rheumatoid arthritis, right hip
	M06.852	Other specified rheumatoid arthritis, left hip
	M06.859	Other specified rheumatoid arthritis, unspecified hip
	M06.861	Other specified rheumatoid arthritis, right knee
	M06.862	Other specified rheumatoid arthritis, left knee
	M06.869	Other specified rheumatoid arthritis, unspecified knee
	M06.871	Other specified rheumatoid arthritis, right ankle and foot
	M06.872	Other specified rheumatoid arthritis, left ankle and foot
	M06.879	Other specified rheumatoid arthritis, unspecified ankle and foot
	M06.88	Other specified rheumatoid arthritis, vertebrae
	M06.89	Other specified rheumatoid arthritis, multiple sites
	M06.9	Rheumatoid arthritis, unspecified
	M08.0A	Unspecified juvenile rheumatoid arthritis, other specified site
	M08.011	Unspecified juvenile rheumatoid arthritis, right shoulder
	M08.012	Unspecified juvenile rheumatoid arthritis, left shoulder

	M08.019	Unspecified juvenile rheumatoid arthritis, unspecified shoulder
	M08.021	Unspecified juvenile rheumatoid arthritis, right elbow
	M08.022	Unspecified juvenile rheumatoid arthritis, left elbow
	M08.029	Unspecified juvenile rheumatoid arthritis, unspecified elbow
	M08.031	Unspecified juvenile rheumatoid arthritis, right wrist
	M08.032	Unspecified juvenile rheumatoid arthritis, left wrist
	M08.039	Unspecified juvenile rheumatoid arthritis, unspecified wrist
	M08.041	Unspecified juvenile rheumatoid arthritis, right hand
	M08.042	Unspecified juvenile rheumatoid arthritis, left hand
	M08.049	Unspecified juvenile rheumatoid arthritis, unspecified hand
	M08.051	Unspecified juvenile rheumatoid arthritis, right hip
	M08.052	Unspecified juvenile rheumatoid arthritis, left hip
	M08.059	Unspecified juvenile rheumatoid arthritis, unspecified hip
	M08.061	Unspecified juvenile rheumatoid arthritis, right knee
	M08.062	Unspecified juvenile rheumatoid arthritis, left knee
	M08.069	Unspecified juvenile rheumatoid arthritis, unspecified knee
	M08.071	Unspecified juvenile rheumatoid arthritis, right ankle and foot
	M08.072	Unspecified juvenile rheumatoid arthritis, left ankle and foot
	M08.079	Unspecified juvenile rheumatoid arthritis, unspecified ankle and foot
	M08.08	Unspecified juvenile rheumatoid arthritis, vertebrae
	M08.09	Unspecified juvenile rheumatoid arthritis, multiple sites
	M08.2A	Juvenile rheumatoid arthritis with systemic onset, other specified site
	M08.211	Juvenile rheumatoid arthritis with systemic onset, right shoulder
	M08.212	Juvenile rheumatoid arthritis with systemic onset, left shoulder
	M08.219	Juvenile rheumatoid arthritis with systemic onset, unspecified shoulder
	M08.221	Juvenile rheumatoid arthritis with systemic onset, right elbow
	M08.222	Juvenile rheumatoid arthritis with systemic onset, left elbow
	M08.229	Juvenile rheumatoid arthritis with systemic onset, unspecified elbow
	M08.231	Juvenile rheumatoid arthritis with systemic onset, right wrist
	M08.232	Juvenile rheumatoid arthritis with systemic onset, left wrist
	M08.239	Juvenile rheumatoid arthritis with systemic onset, unspecified wrist
	M08.241	Juvenile rheumatoid arthritis with systemic onset, right hand
	M08.242	Juvenile rheumatoid arthritis with systemic onset, left hand
	M08.249	Juvenile rheumatoid arthritis with systemic onset, unspecified hand
	M08.251	Juvenile rheumatoid arthritis with systemic onset, right hip
	M08.252	Juvenile rheumatoid arthritis with systemic onset, left hip
	M08.259	Juvenile rheumatoid arthritis with systemic onset, unspecified hip

	M08.261	Juvenile rheumatoid arthritis with systemic onset, right knee
	M08.262	Juvenile rheumatoid arthritis with systemic onset, left knee
	M08.269	Juvenile rheumatoid arthritis with systemic onset, unspecified knee
	M08.271	Juvenile rheumatoid arthritis with systemic onset, right ankle and foot
	M08.272	Juvenile rheumatoid arthritis with systemic onset, left ankle and foot
	M08.279	Juvenile rheumatoid arthritis with systemic onset, unspecified ankle and foot
	M08.28	Juvenile rheumatoid arthritis with systemic onset, vertebrae
	M08.29	Juvenile rheumatoid arthritis with systemic onset, multiple sites
	M08.3	Juvenile rheumatoid polyarthritis (seronegative)
	M08.4A	Pauciarticular juvenile rheumatoid arthritis, other specified site
	M08.411	Pauciarticular juvenile rheumatoid arthritis, right shoulder
	M08.412	Pauciarticular juvenile rheumatoid arthritis, left shoulder
	M08.419	Pauciarticular juvenile rheumatoid arthritis, unspecified shoulder
	M08.421	Pauciarticular juvenile rheumatoid arthritis, right elbow
	M08.422	Pauciarticular juvenile rheumatoid arthritis, left elbow
	M08.429	Pauciarticular juvenile rheumatoid arthritis, unspecified elbow
	M08.431	Pauciarticular juvenile rheumatoid arthritis, right wrist
	M08.432	Pauciarticular juvenile rheumatoid arthritis, left wrist
	M08.439	Pauciarticular juvenile rheumatoid arthritis, unspecified wrist
	M08.441	Pauciarticular juvenile rheumatoid arthritis, right hand
	M08.442	Pauciarticular juvenile rheumatoid arthritis, left hand
	M08.449	Pauciarticular juvenile rheumatoid arthritis, unspecified hand
	M08.451	Pauciarticular juvenile rheumatoid arthritis, right hip
	M08.452	Pauciarticular juvenile rheumatoid arthritis, left hip
	M08.459	Pauciarticular juvenile rheumatoid arthritis, unspecified hip
	M08.461	Pauciarticular juvenile rheumatoid arthritis, right knee
	M08.462	Pauciarticular juvenile rheumatoid arthritis, left knee
	M08.469	Pauciarticular juvenile rheumatoid arthritis, unspecified knee
	M08.471	Pauciarticular juvenile rheumatoid arthritis, right ankle and foot
	M08.472	Pauciarticular juvenile rheumatoid arthritis, left ankle and foot
	M08.479	Pauciarticular juvenile rheumatoid arthritis, unspecified ankle and foot
	M08.48	Pauciarticular juvenile rheumatoid arthritis, vertebrae
	M08.80	Other juvenile arthritis, unspecified site
	M08.811	Other juvenile arthritis, right shoulder
	M08.812	Other juvenile arthritis, left shoulder
	M08.819	Other juvenile arthritis, unspecified shoulder
	M08.821	Other juvenile arthritis, right elbow

	M08.822	Other juvenile arthritis, left elbow
	M08.829	Other juvenile arthritis, unspecified elbow
	M08.831	Other juvenile arthritis, right wrist
	M08.832	Other juvenile arthritis, left wrist
	M08.839	Other juvenile arthritis, unspecified wrist
	M08.841	Other juvenile arthritis, right hand
	M08.842	Other juvenile arthritis, left hand
	M08.849	Other juvenile arthritis, unspecified hand
	M08.851	Other juvenile arthritis, right hip
	M08.852	Other juvenile arthritis, left hip
	M08.859	Other juvenile arthritis, unspecified hip
	M08.861	Other juvenile arthritis, right knee
	M08.862	Other juvenile arthritis, left knee
	M08.869	Other juvenile arthritis, unspecified knee
	M08.871	Other juvenile arthritis, right ankle and foot
	M08.872	Other juvenile arthritis, left ankle and foot
	M08.879	Other juvenile arthritis, unspecified ankle and foot
	M08.88	Other juvenile arthritis, other specified site
	M08.89	Other juvenile arthritis, multiple sites
	M08.9A	Juvenile arthritis, unspecified, other specified site
	M08.911	Juvenile arthritis, unspecified, right shoulder
	M08.912	Juvenile arthritis, unspecified, left shoulder
	M08.919	Juvenile arthritis, unspecified, unspecified shoulder
	M08.921	Juvenile arthritis, unspecified, right elbow
	M08.922	Juvenile arthritis, unspecified, left elbow
	M08.929	Juvenile arthritis, unspecified, unspecified elbow
	M08.931	Juvenile arthritis, unspecified, right wrist
	M08.932	Juvenile arthritis, unspecified, left wrist
	M08.939	Juvenile arthritis, unspecified, unspecified wrist
	M08.941	Juvenile arthritis, unspecified, right hand
	M08.942	Juvenile arthritis, unspecified, left hand
	M08.949	Juvenile arthritis, unspecified, unspecified hand
	M08.951	Juvenile arthritis, unspecified, right hip
	M08.952	Juvenile arthritis, unspecified, left hip
	M08.959	Juvenile arthritis, unspecified, unspecified hip
	M08.961	Juvenile arthritis, unspecified, right knee
	M08.962	Juvenile arthritis, unspecified, left knee

	M08.969	Juvenile arthritis, unspecified, unspecified knee
	M08.971	Juvenile arthritis, unspecified, right ankle and foot
	M08.972	Juvenile arthritis, unspecified, left ankle and foot
	M08.979	Juvenile arthritis, unspecified, unspecified ankle and foot
	M08.98	Juvenile arthritis, unspecified, vertebrae
	M08.99	Juvenile arthritis, unspecified, multiple sites
	M45.0	Ankylosing spondylitis of multiple sites in spine
	M45.1	Ankylosing spondylitis of occipito-atlanto-axial region
	M45.2	Ankylosing spondylitis of cervical region
	M45.3	Ankylosing spondylitis of cervicothoracic region
	M45.4	Ankylosing spondylitis of thoracic region
	M45.5	Ankylosing spondylitis of thoracolumbar region
	M45.6	Ankylosing spondylitis lumbar region
	M45.7	Ankylosing spondylitis of lumbosacral region
	M45.8	Ankylosing spondylitis sacral and sacrococcygeal region
	M45.9	Ankylosing spondylitis of unspecified sites in spine

Applicable Modifiers

Some modifiers.

Policy History

Date	Action	Description
5/10/2024	Policy review	No changes. Policy presented at the Utilization Management Committee MA
12/04/2023	Review Medical Drug Criteria	Added 2023 InterQual® Specialty Rx Criteria.
12/16/2022	New Medical Drug Criteria	New medical drug criteria for Golimumab.

Simponi ARIA® (golimumab)

Renewal Criteria 1,2,3,8

Renewal Criteria ^1,2,3,8