January 28, 2018 at 12:03 am #4630
I’m curious what the experience is for others regarding reimbursement for infliximab for ICI induced colitis/enteritis. I have heard rumblings from colleagues on the inpatient side regarding push back from the third-party payers as it is considered an off label use.
I worry about this given the recent approval of adjuvant nivo. Likely will be seeing more adjuvant agents approved (ie pembro) very soon. I’m wondering what have others heard/experienced?January 29, 2018 at 4:46 am #4632Expert Nurse
This has been an ongoing issue for quite some time now. In my experience the greatest chances of success are coding the ICI related diarrhea as ulcerative colitis ( K51.00-51.8- these codes encompass variations on UC + complications), clinical documentation has to reflect the accompanying diagnosis code.
The greatest issue that we encounter are the delays in approval, that a PA may take several days, so if we suspect that a diarrhea situation may be headed toward needing infliximab, we start the auth process in the out pt setting. Sometimes the coding can be an issue and complicate the process if a coder submits the wrong code, based on their interpretation of the clinical information.
If a patient is referred to our ER for immunotherapy induced diarrhea that is refractory to steroids, we have been successful in patients receiving infliximab in the ER.
In patient, we have not experienced the third party payer issues in quite some time, as the patients are correctly diagnosed and coded upon being admitted for ulcerative colitis.February 2, 2018 at 4:05 pm #4650Expert Nurse
We have had some issues getting infliximab approved for colitis, but as Kathleen said, it is often because the wrong diagnosis code or clinical information is presented. When I have done a peer to peer review because of a denial it has always been approved. Agree that using diagnosis code for colitis helps (K 51.50 has worked for us).
On the other hand, I have not been able to get vedolizumab approved (when a pt is steroid refractory and not improving with infliximab).February 2, 2018 at 5:52 pm #4652
Thanks very much for the info Kathy and Virginia. I will share your comments with the appropriate folks in the billing arena.February 4, 2018 at 2:08 am #4656
Virginia’s comment made me think about this question: How many others are using vedolizumab for infliximab refractory colitis?February 5, 2018 at 2:23 am #4659Expert Nurse
We had a 2 problems this past week (Jan- Feb) achieving a stream line auth for infliximab for 2 pts with grade 4 colitis, steroid refractory. One of our MD’s meet with our financial team & administration.
What emerged from that meeting was the following update & practice suggestion:
The LCD for Medicare was updated 11/1/17 to reflect approval for infliximab
-using the ICD-10 code “K52.1-Toxic Gastroenteritis and Colitis”
. For those patients who do not respond promptly (within 72-96 hours) to therapy with high-dose corticosteroids, Infliximab 5mg/kg may be utilized according to NCCN and ESMO guidelines, and soon ASCO guidelines. It has been included in the BMS algorithms for a decade.
To overcome issues with getting infliximab approved urgently for patients with ICI related diarrhea/ colitis and ensure that the financial team has all appropriate clinical information to obtain insurance authorization, the following is suggested
Clearly document a diagnosis of ICD-10 Code “K52.1-Toxic Gastroenteritis and Colitis” in the following places:
· Progress note for the related encounter
· Problem List
· Diagnosis used for professional billing when you close the encounter
I hope this update will be helpful to all & we will keep you posted with any barriers that we encounter- if any!February 11, 2018 at 8:18 pm #4675Expert Nurse
LCDs can vary state by state. As Kathy mentioned the New York LCD for Medicare was recently changed. However other states may have different icd 10 codes approved for infliximab. Therefore you should check your states LCD to determine the icd 10 codes that are covered. These are available on the internet if you google the drug name and LCD alone with state you are located in.February 15, 2018 at 3:43 pm #4692Expert Nurse
We have not used vendolizumab a lot, but have been able to get it paid for in a handful of patients. Our GI docs have been very instrumental in this process.February 16, 2018 at 4:34 pm #4693Expert Nurse
On that note, I will say that if you use mycophenolate (CellCept), it can take several days to get a PA since it is an oral therapy. We have run into some occasional issues with this.February 17, 2018 at 11:10 pm #4699
Mollie- Has such a delay led to a change in strategy for management?
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