UnitedHealthcare Cimzia Coverage Update: Prior Auth

Coverage Criteria and Medical Necessity

Crohn's Disease — Initial and Continuation Therapy

Cimzia is proven/medically necessary for Crohn's disease when ALL of the following criteria are met.

For initial therapy: Diagnosis of moderately to severely active Crohn's disease; and inadequate response to conventional therapies (examples include anti-inflammatory drugs, corticosteroids, or oral immunosuppressive agents) OR prior treatment with an FDA-approved systemic targeted immunomodulator for Crohn's disease OR patient is currently on Cimzia; Cimzia is initiated and titrated according to US FDA labeled dosing for Crohn's disease; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples: adalimumab, Entyvio (vedolizumab), Omvoh (mirikizumab-mrkz), Rinvoq (upadacitinib), Skyrizi (risankizumab), Tremfya (guselkumab), ustekinumab); prescribed by or in consultation with a gastroenterologist as applicable; initial authorization will be issued for 12 months.

For continuation of therapy: Documentation of positive clinical response; Cimzia is continued and titrated according to US FDA labeled dosing for Crohn's disease; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for treatment of the same indication (examples: adalimumab, Entyvio (vedolizumab), Omvoh (mirikizumab-mrkz), Rinvoq (upadacitinib), Skyrizi (risankizumab), Tremfya (guselkumab), ustekinumab); authorization will be issued for 12 months.

Rheumatoid Arthritis — Initial and Continuation Therapy

Cimzia is proven/medically necessary for rheumatoid arthritis when ALL of the following criteria are met.

For initial therapy: Diagnosis of moderately to severely active rheumatoid arthritis; Cimzia is initiated and titrated according to US FDA labeled dosing for RA; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication (examples: adalimumab, Enbrel (etanercept), Olumiant (baricitinib), Orencia (abatacept), Rinvoq (upadacitinib), Simponi (golimumab), Xeljanz/Xeljanz XR (tofacitinib)); AND one of the following: history of failure or intolerance to a 3-month trial of one non-biologic DMARD at maximally indicated doses unless contraindicated (e.g., methotrexate, leflunomide, sulfasalazine, hydroxychloroquine); OR prior treatment with an FDA-approved systemic targeted immunomodulator for RA; OR patient is currently on Cimzia; prescriber attestation regarding inability to self-administer when applicable (prescriber must submit explanation); prescribed by or in consultation with a rheumatologist; initial authorization will be issued for 12 months.

For continuation of therapy: Documentation of positive clinical response; Cimzia is initiated and titrated according to US FDA labeled dosing for RA; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; prescriber attestation regarding inability to self-administer when applicable; authorization will be issued for 12 months.

Psoriatic Arthritis — Initial and Continuation Therapy

Cimzia is proven/medically necessary for psoriatic arthritis when ALL of the following criteria are met.

For initial therapy: Diagnosis of active psoriatic arthritis; Cimzia is initiated and titrated according to US FDA labeled dosing for PsA; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication (examples: adalimumab, Bimzelx (bimekizumab-bkzx), Cosentyx (secukinumab), Enbrel (etanercept), Orencia (abatacept), Otezla (apremilast), Rinvoq (upadacitinib), Simponi (golimumab), Skyrizi (risankizumab), Taltz (ixekizumab), Tremfya (guselkumab), Xeljanz/Xeljanz XR (tofacitinib), ustekinumab)); AND one of: history of failure to a 3-month trial of methotrexate at maximally indicated dose unless contraindicated; OR prior treatment with an FDA-approved systemic targeted immunomodulator for PsA; OR patient is currently on Cimzia; prescriber attestation regarding inability to self-administer when applicable; prescribed by or in consultation with a rheumatologist or dermatologist; initial authorization will be issued for 12 months.

For continuation of therapy: Documentation of positive clinical response; Cimzia is initiated and titrated according to US FDA labeled dosing for PsA; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; prescriber attestation regarding inability to self-administer when applicable; authorization will be issued for 12 months.

Ankylosing Spondylitis / Non‑Radiographic Axial Spondyloarthritis — Initial and Continuation Therapy

Cimzia is proven/medically necessary for ankylosing spondylitis and non-radiographic axial spondyloarthritis when ALL of the following criteria are met.

For initial therapy: Diagnosis of active ankylosing spondylitis or non-radiographic axial spondyloarthritis; Cimzia is initiated and titrated according to US FDA labeled dosing for AS or nr-axSpA; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication (examples include adalimumab, Bimzelx, Cosentyx, Enbrel, Olumiant, Orencia, Simponi, Rinvoq, Taltz, Xeljanz); AND one of: history of failure to two NSAIDs at maximally indicated doses each used ≥4 weeks unless contraindicated; OR prior treatment with an FDA-approved systemic targeted immunomodulator for AS/nr-axSpA; OR patient is currently on Cimzia; prescriber attestation regarding inability to self-administer when applicable; prescribed by or in consultation with a rheumatologist; initial authorization will be issued for 12 months.

For continuation of therapy: Documentation of positive clinical response; Cimzia is initiated and titrated according to US FDA labeled dosing for AS or nr-axSpA; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; prescriber attestation regarding inability to self-administer when applicable; authorization will be issued for 12 months.

Plaque Psoriasis — Initial and Continuation Therapy

Cimzia is proven/medically necessary for plaque psoriasis when ALL of the following criteria are met.

For initial therapy (proven path): Diagnosis of moderate to severe plaque psoriasis; Cimzia is initiated and titrated according to US FDA labeled dosing for plaque psoriasis; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication (examples include adalimumab, Bimzelx, Cosentyx, Enbrel, Ilumya, Otezla, Skyrizi, Siliq, Sotyktu, Taltz, Tremfya, ustekinumab); initial authorization will be issued for 12 months.

For continuation of therapy: Documentation of positive clinical response; Cimzia is initiated and titrated according to US FDA labeled dosing for plaque psoriasis; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; authorization will be issued for 12 months.

Plaque Psoriasis (Proven)

Cimzia is proven for the treatment of plaque psoriasis when ALL of the following are met.

Plaque Psoriasis - Initial Therapy (proven): Diagnosis of moderate to severe plaque psoriasis; Cimzia initiated and titrated according to US FDA labeled dosing for plaque psoriasis; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; initial authorization for 12 months.

Plaque Psoriasis - Continuation Therapy (proven): Documentation of positive clinical response; Cimzia dosed per US FDA label for plaque psoriasis; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; authorization for 12 months.

Plaque Psoriasis (Medically Necessary with prior therapy requirements)

Cimzia is medically necessary for plaque psoriasis when ALL of the following initial-therapy options are met (one of the following branches must be satisfied).

Branch A - Severity with topical + methotrexate failure: Diagnosis of moderate to severe plaque psoriasis AND one of: greater than or equal to 3% body surface area involvement or palmoplantar, facial, genital involvement, or severe scalp psoriasis; history of failure to one topical therapy unless contraindicated (examples: corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar); AND history of failure to a 3-month trial of methotrexate at the maximally indicated dose unless contraindicated or intolerant.

Topical therapies and methotrexate trial requirements as specified in policy.

Branch B - Prior systemic targeted immunomodulator or current Cimzia: Patient has been previously treated with an FDA-approved systemic targeted immunomodulator for plaque psoriasis OR patient is currently on Cimzia.

Additional requirements: Prescriber attestation that the patient or caregiver cannot be trained or are physically unable to self-administer Cimzia (prescriber must submit explanation) when applicable; Cimzia is initiated and titrated according to US FDA labeled dosing for plaque psoriasis; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; prescribed by or in consultation with a dermatologist; initial authorization will be issued for 12 months.

Polyarticular Juvenile Idiopathic Arthritis — Initial and Continuation Therapy

Cimzia is proven and medically necessary for active polyarticular juvenile idiopathic arthritis when ALL of the following are met.

PJIA - Initial Therapy: Diagnosis of active polyarticular juvenile idiopathic arthritis (PJIA); Cimzia is initiated and titrated according to US FDA labeled dosing for PJIA; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication (examples: adalimumab, Enbrel (etanercept), Olumiant (baricitinib), Orencia (abatacept), Rinvoq (upadacitinib), Simponi (golimumab), Xeljanz/Xeljanz XR (tofacitinib)); prescribed by or in consultation with a rheumatologist for medically necessary pathways requiring attestation; initial authorization is for no more than 12 months.

PJIA - Continuation Therapy: Patient has previously received Cimzia injection for intravenous infusion; documentation of positive clinical response; Cimzia is dosed according to US FDA labeled dosing for PJIA; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; authorization is for no more than 12 months; prescriber attestation regarding inability to self-administer may be required in some medically necessary paths.

Covered when ALL of the following are met

Covered for FDA-indicated conditions when medical necessity criteria are met.

General: Patient has a condition for which Cimzia is FDA-indicated (examples include Crohn's disease; rheumatoid arthritis; psoriatic arthritis; ankylosing spondylitis; non-radiographic axial spondyloarthritis with objective signs of inflammation; moderate-to-severe plaque psoriasis; active polyarticular juvenile idiopathic arthritis in patients >= 2 years of age).

Administration/self-administration: Prescriber must attest and document that the patient or caregiver cannot be trained or are physically unable to self-administer Cimzia when this criterion is required for medical necessity; prescriber must submit explanation (requirement added in 02/01/2026 revision).

02/01/2026 revision added this requirement.

Concomitant therapy restriction: Patient is not receiving specified systemic targeted immunomodulators in combination with Cimzia for the same indication; specific prohibited or example agents vary by indication and were updated in the 02/01/2026 revision.

See updated example agent lists per indication.

Use of Cimzia in combination with another systemic targeted immunomodulator for the treatment of the same indication is not permitted. The policy lists example agents by indication (e.g., adalimumab and multiple other FDA‑approved systemic targeted immunomodulators) and requires that the patient is not receiving Cimzia in combination with those agents for the same diagnosis as a condition of initial or continuation coverage. Requests that include concurrent use for the same indication risk denial. (See indication‑specific example agent lists.)

For all covered indications, Cimzia may not be used as part of combination therapy with another systemic targeted immunomodulator to treat the same condition. The coverage criteria explicitly require that the patient is not receiving Cimzia in combination with a systemic targeted immunomodulator (example agent lists are provided by indication) as a condition for both initial and continuation authorization. Failure to meet this restriction is a denial trigger.

Coverage under this policy is governed by the member’s specific benefit plan. Some Certificates of Coverage may allow experimental, investigational, or off‑label uses under defined circumstances, and certain state mandates can alter coverage for off‑label uses. When such plan language or mandates apply, they take precedence over this policy; the member specific benefit plan document must be consulted to determine applicable coverage.

FDA approvals and the FDA‑labeled indications for Cimzia are provided for informational purposes only. FDA approval alone is not a basis for coverage; treatment must meet the medical necessity criteria set forth in this policy in order to be covered.

Initial Therapy Requirements by Indication

Initial therapy requirements

Initial therapy approvals require diagnosis, prior therapy history or prior biologic use as specified per indication, adherence to FDA labeling, specialist involvement where required, and absence of concurrent systemic targeted immunomodulators.

Initial general: Diagnosis of the relevant condition at the indicated severity; one of: failure/intolerance to specified prior conventional or step therapies per indication, prior treatment with an FDA‑approved systemic targeted immunomodulator for the same indication, OR patient is currently on Cimzia; Cimzia initiated and titrated according to US FDA labeled dosing for the indication; patient not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; prescriber attestation regarding inability to self-administer when applicable; specialist prescribing or consultation required for certain indications (e.g., gastroenterologist for Crohn's disease; rheumatologist for RA/PJIA; dermatologist for plaque psoriasis where specified); initial authorization typically 12 months (PJIA: no more than 12 months).

Specific prior therapy requirements and example agent lists vary by indication and are detailed in each indication-specific section.

Initial Therapy — indication-specific

Indication-specific initial therapy requirements (examples).

Continuation (Renewal) Criteria

Continuation therapy requirements

Continuation therapy requires documentation of clinical benefit and adherence to FDA-labeled dosing; combination therapy with other systemic targeted immunomodulators for the same indication is not allowed.

Continuation general: Documentation of positive clinical response to Cimzia; Cimzia continued and titrated according to US FDA labeled dosing for the relevant indication; patient is not receiving Cimzia in combination with a systemic targeted immunomodulator for the same indication; authorization typically issued for 12 months (PJIA: no more than 12 months).

Continuation Therapy — covered indications

Continuation therapy criteria across covered indications (examples).

Plaque Psoriasis continuation: Documentation of positive clinical response; Cimzia dosed per US FDA label for plaque psoriasis; patient not receiving combination systemic targeted immunomodulator for same indication; authorization typically 12 months.

Step Therapy and Prior Treatment Requirements

Indication	Step 1 prior therapy requirement / note
Ankylosing spondylitis or non‑radiographic axial spondyloarthritis (AS / nr‑axSpA)
History of failure to two NSAIDs (each used ≥4 weeks at maximally indicated doses) unless contraindicated; OR prior treatment with an FDA‑approved systemic targeted immunomodulator for AS/nr‑axSpA; OR currently on Cimzia.

Indication / approval path	Required prior treatment trials
Plaque psoriasis — Branch A (severity + topical/methotrexate path)
≥3% BSA involvement or palmoplantar/facial/genital/severe scalp psoriasis; history of failure to at least one topical therapy (e.g., corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar) AND history of failure to a 3‑month trial of methotrexate at maximally indicated dose unless contraindicated.
Plaque psoriasis — Branch B (prior systemic targeted immunomodulator or current Cimzia)
Prior treatment with an FDA‑approved systemic targeted immunomodulator for plaque psoriasis OR patient currently receiving Cimzia.

Example indication	Illustrative step therapy / prior history
Ankylosing spondylitis / nr‑axSpA
Failure of two NSAIDs (each ≥4 weeks) unless contraindicated; alternatively prior FDA‑approved systemic targeted immunomodulator for AS/nr‑axSpA or current Cimzia use. (Policy update 02/01/2026 revised example agent lists.)
Plaque psoriasis
Either severity/topical + methotrexate failure pathway (≥3% BSA or special-site disease with topical failure and 3‑month methotrexate trial) OR prior treatment with an FDA‑approved systemic targeted immunomodulator OR current Cimzia. (Example systemic agent lists updated 02/01/2026.)
Psoriatic arthritis
History of failure to a 3‑month trial of methotrexate at maximally indicated dose unless contraindicated; OR prior treatment with an FDA‑approved systemic targeted immunomodulator; OR current Cimzia. (Agent lists revised in 2026 updates.)

Procedure and Diagnosis Codes

Procedure CodesHCPCS

J0717

Injection, certolizumab pegol, 1 mg (code may be used when drug administered under the direct supervision of a physician, not for use when drug is self-administered)

Diagnosis Codes (selected excerpts — document contains many more)ICD-10

K31.6	Fistula of stomach and duodenum.
K50.00	Crohn's disease of small intestine without complications.
K50.011	Crohn's disease of small intestine with rectal bleeding.
K50.012	Crohn's disease of small intestine with intestinal obstruction.
K50.013	Crohn's disease of small intestine with fistula.
K50.014	Crohn's disease of small intestine with abscess.
K50.018	Crohn's disease of small intestine with other complication.
K50.019	Crohn's disease of small intestine with unspecified complications.
L40.0	Psoriasis vulgaris.
L40.50	Arthropathic psoriasis, unspecified.

Applicable ICD-10 Codes (rheumatoid myopathy / rheumatoid arthritis)ICD-10Covered

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

Applicable ICD-10 Codes (rheumatoid polyneuropathy and related)ICD-10Covered

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

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Applicable ICD-10 Codes (continued)ICD-10Covered

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

Applicable ICD-10 Codes (M05–M06 series)ICD-10Covered

M05.79	Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
M05.80	Other rheumatoid arthritis with rheumatoid factor of unspecified 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
M06.00	Rheumatoid arthritis without rheumatoid factor, unspecified site
M06.011	Rheumatoid arthritis without rheumatoid factor, right shoulder
M06.012	Rheumatoid arthritis without rheumatoid factor, left shoulder

Applicable ICD-10 Codes (M06 series continued)ICD-10Covered

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
M06.051	Rheumatoid arthritis without rheumatoid factor, right hip
M06.052	Rheumatoid arthritis without rheumatoid factor, left hip
M06.061	Rheumatoid arthritis without rheumatoid factor, right knee
M06.062	Rheumatoid arthritis without rheumatoid factor, left knee
M06.08	Rheumatoid arthritis without rheumatoid factor, vertebrae

Applicable ICD-10 Codes (bursitis, nodules, other specified RA)ICD-10Covered

M06.1	Adult-onset Still's disease
M06.20	Rheumatoid bursitis, unspecified site
M06.211	Rheumatoid bursitis, right shoulder
M06.231	Rheumatoid bursitis, right wrist
M06.30	Rheumatoid nodule, unspecified site
M06.311	Rheumatoid nodule, right shoulder
M06.321	Rheumatoid nodule, right elbow

Applicable ICD-10 Codes (other specified RA and inflammatory polyarthropathy)ICD-10Covered

M06.331	Rheumatoid nodule, right wrist
M06.351	Rheumatoid nodule, right hip
M06.361	Rheumatoid nodule, right knee
M06.39	Inflammatory polyarthropathy
M06.80	Other specified rheumatoid arthritis, unspecified site
M06.811	Other specified rheumatoid arthritis, right shoulder
M06.831	Other specified rheumatoid arthritis, right wrist

Applicable ICD-10 Codes (juvenile arthritis series)ICD-10Covered

M06.9	Rheumatoid arthritis, unspecified
M08.00	Unspecified juvenile rheumatoid arthritis of unspecified site
M08.011	Unspecified juvenile rheumatoid arthritis, right shoulder
M08.031	Unspecified juvenile rheumatoid arthritis, right wrist
M08.1	Juvenile ankylosing spondylitis
M08.20	Juvenile rheumatoid arthritis with systemic onset, unspecified site

Applicable ICD-10 Codes (juvenile arthritis continued)ICD-10Covered

M08.231	Juvenile rheumatoid arthritis with systemic onset, right wrist
M08.241	Juvenile rheumatoid arthritis with systemic onset, right hand
M08.3	Juvenile rheumatoid polyarthritis (seronegative)
M08.80	Other juvenile arthritis, unspecified site
M08.811	Other juvenile arthritis, right shoulder

Applicable ICD-10 Codes (juvenile arthritis continuation and M45 series)ICD-10Covered

M08.951	Juvenile arthritis, unspecified, right hip
M08.961	Juvenile arthritis, unspecified, right knee
M08.971	Juvenile arthritis, unspecified, right ankle and foot
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

Applicable ICD-10 Codes (M45 series continued)ICD-10Covered

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

Juvenile arthritis ICD-10 codesICD-10

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, vertebrae

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Ankylosing spondylitis and related codesICD-10

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

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Additional spondylopathies and fistula ICD-10 codesICD-10

M45.9	Ankylosing spondylitis of unspecified sites in spine
M45.A0	Non-radiographic axial spondyloarthritis of unspecified sites in spine
M45.A1	Non-radiographic axial spondyloarthritis of occipito-atlanto-axial region
M45.A2	Non-radiographic axial spondyloarthritis of cervical region
M45.A3	Non-radiographic axial spondyloarthritis of cervicothoracic region
M45.A4	Non-radiographic axial spondyloarthritis of thoracic region
M45.A5	Non-radiographic axial spondyloarthritis of thoracolumbar region
M45.A6	Non-radiographic axial spondyloarthritis of lumbar region
M45.A7	Non-radiographic axial spondyloarthritis of lumbosacral region
M45.A8	Non-radiographic axial spondyloarthritis of sacral and sacrococcygeal region

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Coding

CodingNone specified

NotesNo additional procedure or CPT codes specified in this section; see procedure code J0717 in procedure codes list elsewhere in policy.

Policy effective date02/01/2026

Age for pJIA

Prior Authorization, Documentation, and Billing Guidance

Documentation Required

Diagnosis code required for prior authorization

Use one of the listed ICD-10 diagnosis codes on prior authorization requests and claim submissions; requests or claims that do not include an applicable diagnosis code may be inconsistent with policy and delay processing.

Include an appropriate ICD-10 code that supports the requested indication on all prior authorization requests and claims.

Note

Benefit document governs

The member specific benefit plan document governs coverage determinations. Before relying on this policy, check the memberspecific benefit plan and any applicable federal or state mandates. In the event of a conflict, the member specific benefit plan document controls.

This policy is informational and may not reflect member-specific exceptions or mandates.
For Medicare Advantage members, in the absence of an applicable NCD or LCD, the MAO may apply its own coverage determinations per CMS guidance.

Background and Drug Information

Cimzia (certolizumab pegol) is a recombinant, humanized antibody Fab' fragment that selectively neutralizes tumor necrosis factor alpha (TNFα) and is pegylated. It is indicated for multiple inflammatory conditions, including reduction of signs and symptoms and maintenance of clinical response in moderately to severely active Crohn’s disease, treatment of moderately to severely active rheumatoid arthritis, active psoriatic arthritis, active ankylosing spondylitis and non‑radiographic axial spondyloarthritis with objective signs of inflammation, moderate‑to‑severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy, and active polyarticular juvenile idiopathic arthritis in patients aged >= 2 years. Coverage under this policy ties authorization to meeting the indication‑specific medical necessity criteria and FDA‑labeled dosing.

Definitions and Key Terms

Benefit determination

Benefit determination — usual settingSelf-administered Cimzia is generally obtained under the pharmacy benefit unless otherwise specified in the member’s benefit plan.

ExceptionFor UnitedHealthcare of California members with delegated prior authorization review, self-administered Cimzia may be obtained under the medical benefit.

Governing documentMember-specific benefit plan documents determine final benefit responsibility.

Moderate to severe plaque psoriasis

DefinitionModerate to severe plaque psoriasis defined as >=3% body surface area involvement, or palmoplantar, facial, genital involvement, or severe scalp psoriasis.

Topical therapy requirementHistory of failure to one topical therapy unless contraindicated or significant adverse effects occur (examples listed in policy).

Site of Care and Benefit Placement

Billing Rule

Site of care / benefit placement — pharmacy benefit unless plan specifies otherwise

Self‑administered Cimzia is generally obtained under the pharmacy benefit unless the member's benefit plan specifies otherwise; check the member specific benefit plan for benefit placement.

Policy Revision History

2026-02-01policy_revisionLatest

Added prescriber attestation requirement that the patient or caregiver cannot be trained or are physically unable to self‑administer Cimzia and must submit an explanation; updated lists of systemic targeted immunomodulators (examples added, removed, or replaced) across multiple indications (Crohn's disease, PsA, AS/nr‑axSpA, plaque psoriasis, PJIA).

2026-02-01coding_update

Removed CPT codes 96372 and 96401 from the applicable codes list.

2026-02-01

OpenPayer

Cimzia (Certolizumab Pegol) Coverage Criteria