Infliximab (J1745, Q5103, Q5104): Medicare covered diagnoses & ICD-10 codes

What Medicare pays for Infliximab (2026 Q3)

Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:

Source: CMS ASP Drug Pricing File, 2026 Q3. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →

Infliximab is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J1745, Q5103, Q5104, Q5121) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).

Covered ICD-10 diagnoses for Infliximab

The 406 codes below are the diagnoses Palmetto GBA accepts for J1745 under Article A56432, grouped exactly as CMS groups them and organized by condition category for scanning. Use the filter in each group to find a specific code or condition.

What commercial payers require for Infliximab

Medicare Part B is only half the answer — most Infliximab claims are adjudicated by a commercial plan with its own medical policy. Below is what 30 commercial payers publish for Infliximab, read from each payer's own policy document. 25 of 30 that state a position require prior authorization, and 17 run a site-of-care program that can push the infusion out of the hospital outpatient setting. 20 name a preferred product you must try or fail first.

What Infliximab payers put in writing

Quoted from the medical policies linked above — 24 distinct requirements across 30 payers. These are the sentences an appeal has to answer.

Clinical prerequisites — what must be true before they pay

• The requested medication must be prescribed in combination with methotrexate or leflunomide unless the member has a clinical reason not to use methotrexate or leflunomide— BCBS Tennessee, HMSA (BCBS Hawaii), Wellmark BCBS policy ↗
• Prescribed by or in consultation with a rheumatologist— Blue Shield of California, Centene / Ambetter, UnitedHealthcare policy ↗
• Member has had an inadequate response or intolerance to either phototherapy (e.g., UVB, PUVA) or pharmacologic treatment with methotrexate, cyclosporine, or acitretin.— BCBS Tennessee, CareFirst BCBS policy ↗
• Prescribed by or in consultation with a gastroenterologist— Centene / Ambetter, UnitedHealthcare policy ↗
• The medication is prescribed by or in consultation with a gastroenterologist— Cigna, Premera Blue Cross policy ↗
• Authorization of 12 months may be granted for adult members who have previously received a biologic or targeted synthetic drug (e.g., Rinvoq, Xeljanz) indicated for moderately to severely active rheumatoid arthritis— HMSA (BCBS Hawaii), Wellmark BCBS policy ↗

Prior authorization

• Note : Requires Precertification: Precertification of an infliximab product is required of all Aetna participating providers and members in applicable plan designs.— Aetna policy ↗
• When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical— Anthem / Elevance policy ↗
• Effective April 01, 2022 Prior Approval is required for Infliximab (e.g., Remicade and Unbranded Infliximab) and Biosimilars.— Arkansas BCBS policy ↗
• Prior authorization is required to ensure the safe, clinically appropriate, and cost-effective use of infliximab while maintaining optimal therapeutic outcomes.— BCBS Federal Employee Program policy ↗
• For BCBS KS, this program only targets the following non-preferred infliximab agents: Infliximab, Remicade, Renflexis— BCBS Kansas policy ↗
• This policy covers prior authorization, step therapy and quantity limit requirements for immune modulating— BCBS Massachusetts policy ↗

Quantity and frequency limits

• Remicade (infliximab) 100 mg vial 5 mg/kg as frequently as every 8 weeks— Anthem / Elevance policy ↗
• The dosage prescribed does NOT exceed 10 mg/kg every 4 weeks— Florida Blue policy ↗
• The requested dose does NOT exceed 10 mg/kg every 4 weeks— BCBS Kansas policy ↗
• Members 18 years of age or older who respond to 5 mg/kg every 8 weeks and then lose response may be approved for 10 mg/kg every 8 weeks.— BCBS Louisiana policy ↗
• Members who have had an incomplete response to 3 mg/kg every 8 weeks may be approved for a dose of up to 10 mg/kg every 8 weeks.— BCBS Louisiana policy ↗
• Quantity Limits: Align with FDA recommended dosing— BCBS Michigan policy ↗

Dosing rules

• Ankylosing spondylitis (adults) Induction: 5 mg/kg IV at weeks 0, 2, and 6 Maintenance: 5 mg/kg IV every 6 weeks— Aetna policy ↗
• Crohn's disease, moderate-to-severe (pediatrics 6 years of age and older) Induction: 5 mg/kg IV at weeks 0, 2, and 6 Maintenance: 5 mg/kg IV every 8 weeks— Aetna policy ↗
• Plaque psoriasis, chronic (severe) (adults) Induction: 5 mg/kg IV at weeks 0, 2, and 6 Maintenance: 5 mg/kg IV every 8 weeks— Aetna policy ↗
• Psoriasis arthritis (adults) Induction: 5 mg/kg at weeks 0, 2, and 6 Maintenance: 5 mg/kg IV every 8 weeks— Aetna policy ↗
• Ulcerative colitis (6 years of age and older) Induction: 5 mg/kg IV at weeks 0, 2 and 6 Maintenance: 5 mg/kg IV every 8 weeks— Aetna policy ↗
• For Rheumatoid Arthritis (RA), may approve dose escalation up to 10 mg/kg every 8 weeks OR 3 mg/kg— Anthem / Elevance policy ↗

Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.

How to bill Infliximab

Put the patient's covered ICD-10 diagnosis on the claim line with J1745. Matching codes, units and JZ/JW wastage →

Which policy governs Infliximab

The covered code lists live in Article A56432 (tied to LCD L35677) — CMS moved code lists out of LCDs and into Articles, which is why the diagnoses live in the Article. What an LCD, an Article and an NCD each govern →

If a claim for Infliximab is denied

The usual cause is a diagnosis outside Article A56432's covered list, or a product code and unit count that do not match what was given. The five denial patterns and how to fix each →