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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that Medicare may cover a drug or biological if it is safe and effective and otherwise reasonable 
and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.1. 
 
The rules say that the use of infliximab will be considered to be medically reasonable and necessary in the 
following circumstances: 
 
1. To reduce the signs and symptoms, and induce and maintain clinical remission in adult and pediatric patients 
with moderately to severely active Crohns disease in patients who have had an inadequate response to 
conventional therapy (e.g., corticosteroids, aminosalicylates, and immunosuppressive agents). 
2. To reduce the number of draining enterocutaneous and rectovaginal fistulas and maintaining fistula closure 
for patients with fistulizing Crohns disease. Normally, the patient receives an infusion for this indication at 
weeks 0, 2 & 6. Subsequent treatments will be covered if the patient responds to the initial treatment as 
demonstrated by a reduction in signs and symptoms. 
3. To reduce the signs and symptoms of active arthritis, inhibiting the progression of structural damage and 
improving physical function, in patients with psoriatic arthritis. Normally, the patient receives an infusion for 
this indication at weeks 0, 2 & 6. Subsequent treatments will be covered if the patient responds to the initial 
treatment as demonstrated by a reduction in signs and symptoms. 
4. When used in combination with methotrexate, to reduce the signs and symptoms, inhibit the progression of 
structural damage and improve physical function in patients with moderately to severely active rheumatoid 
arthritis. Normally, the patient receives an infusion of infliximab for this indication at weeks 0, 2 & 6 and then 
approximately every 8 weeks. 
5. To reduce the signs and symptoms in patients with active ankylosing spondylitis. Normally the patient 
receives an infusion for this indication at 0, 2 & 6 weeks. Subsequent treatment will be covered if the patient 
responds to the initial treatment as demonstrated by a reduction in signs and symptoms. 
6. For the treatment of adult patients with chronic severe plaque psoriasis (as evidenced by plaques covering at 
least 10% of the body surface) who have failed prior treatment with psoralen-ultraviolet A (UVA), or 
ultraviolet B (UVB) light therapy; or are candidates for systemic therapy when other conventional systemic 
therapies have failed (methotrexate, cyclosporine, Soriatane); or the patient has contraindications to these 
treatments. Infliximab should only be administered to patients who will be closely monitored and have regular 
follow-up visits with a physician. Normally the patient receives an infusion at 0, 2 & 6 weeks and every 8 
weeks thereafter. 
7. To reduce signs and symptoms, achieve clinical remission and mucosal healing, and eliminate corticosteroid 
use in patients with moderately to severely active ulcerative colitis who have had an inadequate response to 
conventional therapy, such as aminosalicylates, corticosteroids, or immunosuppressants (unless the patient is 
unable to tolerate these drugs). Normally, the patient receives an infusion for this indication at 0, 2 & 6 weeks, 
and then every 8 weeks thereafter. 
8. As an off-label use for reactive arthritis and  inflammatory bowel disease (e.g,. Reiters syndrome who have 
failed or are intolerant to non-steroidal anti-inflammatory drugs (NSAIDs), methotrexate and sulfasalazine). 
9. As an off-label use for hidradenitis suppurativa in the treatment of persons with severe disease refractory to 
systemic antibiotics and surgical treatments. 
10. As an off-label use for Behcets Disease (BD), also known as Behcets Syndrome, in patients without an 
adequate response to initial therapy, for the treatment of clinical manifestations of BD such as severe ocular 
involvement, major organ involvement, severe gastrointestinal or neurological involvement and resistant cases 
of joint or mucocutaneous involvement (i.e., painful oral and genital ulcers). 
11. As an off-label use for patients with chronic pulmonary sarcoidosis who remain symptomatic despite 
treatment for 3 or more months with steroids (10 mg per day or more) and immunosuppressants (such as 
azathioprine, cyclophosphamide or methotrexate) or have a contraindication or intolerance to one 
immunosuppressant (such as azathioprine, cyclophosphamide, or methotrexate) and the patient is not receiving 
infliximab in combination with either of the following: 1) Biologic disease-modifying anti-rheumatic 
drugs (DMARDs) [e.g., Enbrel (etanercept), Humira (adalimumab), Cimzia (certolizumab), Simponi 
(golimumab)] 2) Janus kinase inhibitor [e.g., Xeljanz (tofacitinib)]. The current and prospective roles of infliximab in the treatment of pulmonary sarcoidosis do not currently have food and drug administration (FDA) 
approval; therefore, it is recommended that providers consult the literature for proper dosing of infliximab. 
 
You can find this rule in the Local Coverage Determination (LCD) - Infliximab (L35677) - Effective August 5, 
2021. 
 
The rules say that Infliximab will only be covered for the above indications when no contraindications to its 
use exist including: 
 
a. Class III or IV congestive heart failure; or 
b. Untreated active or latent tubercolosis 
 
You can find this rule in the Local Coverage Determination (LCD) - Infliximab (L35677) - Effective August 5, 
2021. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.