Byetta (Exenatide Injection)

Transcription

1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document Drugs requiring prior authorization: the list of drugs requiring prior authorization for this clinical edit Prior authorization criteria logic: a description of how the prior authorization request will be evaluated against the clinical edit criteria rules Logic diagram: a visual depiction of the clinical edit criteria logic Supporting tables: a collection of information associated with the steps within the criteria (diagnosis codes, procedure codes, and therapy codes); provided when applicable References: clinical publications and sources relevant to this clinical edit Note: Click the hyperlink to navigate directly to that section. Revision Notes Updated to include ICD-10s. April 3, 2015 Copyright Health Information Designs, LLC 1

2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN BYETTA 5 MCG DOSE PEN INJ BYETTA 10 MCG DOSE PEN INJ April 3, 2015 Copyright Health Information Designs, LLC 2

3 Clinical Edit Criteria Logic 1. Is the client greater than or equal to ( ) 18 years of age? [ ] Yes (Go to #2) [ ] No (Deny) 2. Does the client have a diagnosis of type II diabetes in the last 365 days? [ ] Yes (Go to #3) [ ] No (Deny) 3. Does the client have a history of a prior oral antidiabetic agent for 14 days in the last 365 days? [ ] Yes (Go to #4) [ ] No (Deny) 4. Does the client have a history of ESRD, chronic kidney disease (stage IV and V), pancreatitis, or severe GI disease in the last 730 days? [ ] Yes (Deny) [ ] No (Go to #5) 5. Does the client have a history of ESRD services (CPT codes) in the last 730 days? [ ] Yes (Deny) [ ] No (Go to #6) 6. Does the client have a history of an HbA1c test in the last 180 days? [ ] Yes (Go to #7) [ ] No (Deny) 7. Is the dose less than or equal to ( ) 10 mcg per day? [ ] Yes (Approve 365 days) [ ] No (Go to #8) 8. Does the client have a history of exenatide for 14 days in the last 365 days? [ ] Yes (Approve 365 days) [ ] No (Deny) April 3, 2015 Copyright Health Information Designs, LLC 3

4 Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client > 18 years of age? Yes Does the client have a diagnosis of type II diabetes in the last 365 days? Yes Does the client have a history of a prior oral antidiabetic agent for 14 days in the last 365 days? No Deny Request No No Yes Step 4 Deny Request Deny Request Does the client have a history of ESRD, chronic kidney disease (stage IV and V), pancreatitis or severe GI disease in the last 730 days? Yes Deny Request No Step 6 Step 5 Deny Request No Does the client have a history of an HbA1c test in the last 180 days? No Does the client have a history of ESRD services (CPT codes) in the last 730 days? Yes Deny Request Yes Step 7 Step 8 Approve Request (365 days) Yes Is the dose 10 mcg per day? No Does the client have a history of exenatide for 14 days in the last 365 days? No Deny Request Yes Approve Request (365 days) April 3, 2015 Copyright Health Information Designs, LLC 4

5 Clinical Edit Criteria Supporting Tables ICD-9 Code Step 2 (diagnosis of type II diabetes) Description Look back timeframe: 365 days DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE UNCONTROLLED April 3, 2015 Copyright Health Information Designs, LLC 5

6 Step 2 (diagnosis of type II diabetes) Look back timeframe: 365 days DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED ICD-10 Code E139 E119 E1310 E1101 E1301 E1100 E1300 E13641 E11641 E1311 E1322 E1329 E1121 E1122 E1129 E1321 E1336 E13331 E13339 E13351 E13359 Description OTHER SPECIFIED DIABETES MELLITUS WITHOUT TYPE 2 DIABETES MELLITUS WITHOUT OTHER SPECIFIED DIABETES MELLITUS WITH KETOACIDOSIS WITHOUT COMA TYPE 2 DIABETES MELLITUS WITH HYPEROSMOLARITY WITH COMA OTHER SPECIFIED DIABETES MELLITUS WITH HYPEROSMOLARITY WITH COMA TYPE 2 DIABETES MELLITUS WITH HYPEROSMOLARITY WITHOUT NONKETOTIC HYPERGLYCEMIC-HYPEROSMOLAR COMA (NKHHC) OTHER SPECIFIED DIABETES MELLITUS WITH HYPEROSMOLARITY WITHOUT NONKETOTIC HYPERGLYCEMIC-HYPEROSMOLAR COMA (NKHHC) OTHER SPECIFIED DIABETES MELLITUS WITH HYPOGLYCEMIA WITH COMA TYPE 2 DIABETES MELLITUS WITH HYPOGLYCEMIA WITH COMA OTHER SPECIFIED DIABETES MELLITUS WITH KETOACIDOSIS WITH COMA OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE OTHER SPECIFIED DIABETES MELLITUS WITH OTHER DIABETIC KIDNEY COMPLICATION TYPE 2 DIABETES MELLITUS WITH DIABETIC NEPHROPATHY TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE TYPE 2 DIABETES MELLITUS WITH OTHER DIABETIC KIDNEY COMPLICATION OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC NEPHROPATHY OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC CATARACT OTHER SPECIFIED DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA OTHER SPECIFIED DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA OTHER SPECIFIED DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA April 3, 2015 Copyright Health Information Designs, LLC 6

7 E13341 E13349 E13311 E1339 E13329 E11341 E11359 E1136 E1139 E13319 E13321 E11351 E11311 E11319 E11331 E11339 E11321 E11329 E11349 E1140 E1142 E1149 Step 2 (diagnosis of type II diabetes) Look back timeframe: 365 days OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA OTHER SPECIFIED DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA OTHER SPECIFIED DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITH MACULAR EDEMA OTHER SPECIFIED DIABETES MELLITUS WITH OTHER DIABETIC OPHTHALMIC COMPLICATION OTHER SPECIFIED DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH DIABETIC CATARACT TYPE 2 DIABETES MELLITUS WITH OTHER DIABETIC OPHTHALMIC COMPLICATION OTHER SPECIFIED DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA OTHER SPECIFIED DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITH MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH MODERATE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY TYPE 2 DIABETES MELLITUS WITH OTHER DIABETIC NEUROLOGICAL COMPLICATION April 3, 2015 Copyright Health Information Designs, LLC 7

8 E1140 E1141 E1143 E1144 E1149 E11610 E1340 E1342 E1349 E1340 E1341 E1343 E1344 E1349 E13610 E1151 E1152 E1159 E1351 E1352 E1359 E1365 E1369 E13622 Step 2 (diagnosis of type II diabetes) Look back timeframe: 365 days TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED TYPE 2 DIABETES MELLITUS WITH DIABETIC MONONEUROPATHY TYPE 2 DIABETES MELLITUS WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY TYPE 2 DIABETES MELLITUS WITH DIABETIC AMYOTROPHY TYPE 2 DIABETES MELLITUS WITH OTHER DIABETIC NEUROLOGICAL COMPLICATION TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHIC ARTHROPATHY OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY OTHER SPECIFIED DIABETES MELLITUS WITH OTHER DIABETIC NEUROLOGICAL COMPLICATION OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC MONONEUROPATHY OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC AMYOTROPHY OTHER SPECIFIED DIABETES MELLITUS WITH OTHER DIABETIC NEUROLOGICAL COMPLICATION OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC NEUROPATHIC ARTHROPATHY TYPE 2 DIABETES MELLITUS WITH DIABETIC PERIPHERAL ANGIOPATHY WITHOUT GANGRENE TYPE 2 DIABETES MELLITUS WITH DIABETIC PERIPHERAL ANGIOPATHY WITH GANGRENE TYPE 2 DIABETES MELLITUS WITH OTHER CIRCULATORY OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC PERIPHERAL ANGIOPATHY WITHOUT GANGRENE OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC PERIPHERAL ANGIOPATHY WITH GANGRENE OTHER SPECIFIED DIABETES MELLITUS WITH OTHER CIRCULATORY OTHER SPECIFIED DIABETES MELLITUS WITH HYPERGLYCEMIA OTHER SPECIFIED DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATION OTHER SPECIFIED DIABETES MELLITUS WITH OTHER SKIN ULCER April 3, 2015 Copyright Health Information Designs, LLC 8

9 E13628 E13630 E13649 E13621 E13638 E13618 E1165 E1169 E13620 E11620 E11622 E11628 E11630 E11638 E11649 E11621 E11618 E118 E138 Step 2 (diagnosis of type II diabetes) Look back timeframe: 365 days OTHER SPECIFIED DIABETES MELLITUS WITH OTHER SKIN OTHER SPECIFIED DIABETES MELLITUS WITH PERIODONTAL DISEASE OTHER SPECIFIED DIABETES MELLITUS WITH HYPOGLYCEMIA WITHOUT COMA OTHER SPECIFIED DIABETES MELLITUS WITH FOOT ULCER OTHER SPECIFIED DIABETES MELLITUS WITH OTHER ORAL OTHER SPECIFIED DIABETES MELLITUS WITH OTHER DIABETIC ARTHROPATHY TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATION OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC DERMATITIS TYPE 2 DIABETES MELLITUS WITH DIABETIC DERMATITIS TYPE 2 DIABETES MELLITUS WITH OTHER SKIN ULCER TYPE 2 DIABETES MELLITUS WITH OTHER SKIN TYPE 2 DIABETES MELLITUS WITH PERIODONTAL DISEASE TYPE 2 DIABETES MELLITUS WITH OTHER ORAL TYPE 2 DIABETES MELLITUS WITH HYPOGLYCEMIA WITHOUT COMA TYPE 2 DIABETES MELLITUS WITH FOOT ULCER TYPE 2 DIABETES MELLITUS WITH OTHER DIABETIC ARTHROPATHY TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED OTHER SPECIFIED DIABETES MELLITUS WITH UNSPECIFIED Step 3 (history of oral antidiabetic agent) Required quantity: 1 Look back timeframe: 365 days Label Name GCN ACARBOSE 25 MG TABLET ACARBOSE 50 MG TABLET ACARBOSE 100 MG TABLET ACTOPLUS MET 15 MG-500 MG TAB ACTOPLUS MET 15 MG-850 MG TAB ACTOPLUS MET XR 15-1,000 MG TB ACTOPLUS MET XR 30-1,000 MG TB ACTOS 15 MG TABLET ACTOS 30 MG TABLET April 3, 2015 Copyright Health Information Designs, LLC 9

10 Step 3 (history of oral antidiabetic agent) Required quantity: 1 Look back timeframe: 365 days Label Name GCN ACTOS 45 MG TABLET AMARYL 1 MG TABLET AMARYL 2 MG TABLET AMARYL 4 MG TABLET AVANDAMET 2 MG-500 MG TABLET AVANDAMET 2 MG-1,000 MG TAB AVANDAMET 4 MG-500 MG TABLET AVANDAMET 4 MG-1,000 MG TABLET AVANDARYL 4 MG-1 MG TABLET AVANDARYL 4 MG-2 MG TABLET AVANDARYL 4 MG-4 MG TABLET AVANDARYL 8 MG-2 MG TABLET AVANDARYL 8 MG-4 MG TABLET AVANDIA 2 MG TABLET AVANDIA 4 MG TABLET AVANDIA 8 MG TABLET CHLORPROPAMIDE 100 MG TABLET CHLORPROPAMIDE 250 MG TABLET DIABETA 1.25 MG TABLET DIABETA 2.5 MG TABLET DIABETA 5 MG TABLET DUETACT 30-2 MG TABLET DUETACT 30-4 MG TABLET FORTAMET ER 500 MG TABLET FORTAMET ER 1,000 MG TABLET GLIMEPIRIDE 1 MG TABLET GLIMEPIRIDE 2 MG TABLET GLIMEPIRIDE 4 MG TABLET GLIPIZIDE 5 MG TABLET GLIPIZIDE 10 MG TABLET GLIPIZIDE ER 2.5 MG TABLET GLIPIZIDE ER 5 MG TABLET GLIPIZIDE ER 10 MG TABLET GLIPIZIDE XL 2.5 MG TABLET GLIPIZIDE XL 5 MG TABLET GLIPIZIDE XL 10 MG TABLET April 3, 2015 Copyright Health Information Designs, LLC 10

11 Step 3 (history of oral antidiabetic agent) Required quantity: 1 Look back timeframe: 365 days Label Name GCN GLIPIZIDE-METFORMIN MG GLIPIZIDE-METFORMIN MG GLIPIZIDE-METFORMIN MG GLUCOPHAGE 500 MG TABLET GLUCOPHAGE 850 MG TABLET GLUCOPHAGE 1,000 MG TABLET GLUCOPHAGE XR 500 MG TAB GLUCOPHAGE XR 750 MG TAB GLUCOTROL 5 MG TABLET GLUCOTROL 10 MG TABLET GLUCOTROL XL 2.5 MG TABLET GLUCOTROL XL 5 MG TABLET GLUCOTROL XL 10 MG TABLET GLUCOVANCE MG TABLET GLUCOVANCE MG TABLET GLUMETZA ER 500 MG TABLET GLUMETZA ER 1,000 MG TABLET GLYBURIDE 1.25 MG TABLET GLYBURIDE 2.5 MG TABLET GLYBURIDE 5 MG TABLET GLYBURIDE MICRO 1.5 MG TAB GLYBURIDE MICRO 3 MG TABLET GLYBURIDE MICRO 6 MG TABLET GLYBURIDE-METFORMIN MG GLYBURIDE-METFORMIN MG GLYNASE 1.5 MG PRESTAB GLYNASE 3 MG PRESTAB GLYNASE 6 MG PRESTAB GLYSET 25 MG TABLET GLYSET 50 MG TABLET GLYSET 100 MG TABLET JANUMET MG TABLET JANUMET 50-1,000 MG TABLET JANUVIA 25 MG TABLET JANUVIA 50 MG TABLET JANUVIA 100 MG TABLET April 3, 2015 Copyright Health Information Designs, LLC 11

12 Step 3 (history of oral antidiabetic agent) Required quantity: 1 Look back timeframe: 365 days Label Name GCN KOMBIGLYZE XR 2.5-1,000 MG TAB KOMBIGLYZE XR MG TABLET KOMBIGLYZE XR 5-1,000 MG TAB METAGLIP MG TABLET METAGLIP MG TABLET METFORMIN HCL 500 MG TABLET METFORMIN HCL 850 MG TABLET METFORMIN HCL 1,000 MG TABLET METFORMIN HCL ER 500 MG TABLET METFORMIN HCL ER 750 MG TABLET NATEGLINIDE 60 MG TABLET NATEGLINIDE 120 MG TABLET ONGLYZA 2.5 MG TABLET ONGLYZA 5 MG TABLET PRANDIMET 1 MG-500 MG TABLET PRANDIMET 2 MG-500 MG TABLET PRANDIN 0.5 MG TABLET PRANDIN 1 MG TABLET PRANDIN 2 MG TABLET PRECOSE 25 MG TABLET PRECOSE 50 MG TABLET PRECOSE 100 MG TABLET RIOMET 500 MG/5 ML SOLUTION STARLIX 60 MG TABLET STARLIX 120 MG TABLET TOLAZAMIDE 250 MG TABLET TOLAZAMIDE 500 MG TABLET TOLBUTAMIDE 500 MG TABLET April 3, 2015 Copyright Health Information Designs, LLC 12

13 ICD-9 Code Step 4 (diagnosis of ESRD, CKD, pancreatitis, or severe GI disease) Description Look back timeframe: 730 days HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 5311 ACUTE GASTRIC ULCER WITH PERFORATION 5312 ACUTE GASTRIC ULCER WITH HEMORRHAGE AND PERFORATION 5315 CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH PERFORATION 5316 CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH HEMORRHAGE AND PERFORATION 5321 ACUTE DUODENAL ULCER WITH PERFORATION 5322 ACUTE DUODENAL ULCER WITH HEMORRHAGE AND PERFORATION 5325 CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH PERFORATION 5326 CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH HEMORRHAGE AND PERFORATION 5331 ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH PERFORATION 5332 ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE AND PERFORATION 5335 CHRONIC OR UNSPECIFIED PEPTIC ULCER OF UNSPECIFIED SITE WITH PERFORATION 5336 CHRONIC OR UNSPECIFIED PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE AND PERFORATION 5341 ACUTE GASTROJEJUNAL ULCER WITH PERFORATION GASTROPARESIS ACUTE GASTROJEJUNAL ULCER WITH HEMORRHAGE AND PERFORATION CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER WITH PERFORATION CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER WITH HEMORRHAGE AND PERFORATION 5372 CHRONIC DUODENAL ILEUS 555 REGIONAL ENTERITIS 5550 REG ENTERITIS, SM INTEST 5551 REG ENTERITIS, LG INTEST 5552 REG ENTERIT SM/LG INTEST 5559 REGIONAL ENTERITIS NOS 556 ULCERATIVE ENTEROCOLITIS 5560 ULCERATIVE ENTEROCOLITIS 5561 ULCERATIVE ILEOCOLITIS 5562 ULCERATIVE PROCTITIS April 3, 2015 Copyright Health Information Designs, LLC 13

14 Step 4 (diagnosis of ESRD, CKD, pancreatitis, or severe GI disease) Look back timeframe: 730 days 5563 ULCERTVE PRCTOSIGMOIDTIS 5564 PSEUDOPOLYPOSIS COLON 5565 LFTSDED ULCERTVE COLITIS 5566 UNIVRSL ULCERTVE COLITIS 5568 OTHER ULCERATIVE COLITIS 5569 ULCERATVE COLITIS UNSPCF 5589 NONINF GASTROENTERIT NEC 560 INTESTINAL WITHOUT MENTION OF HERNIA 5600 INTUSSUSCEPTION 5601 PARALYTIC ILEUS 5602 VOLVULUS OF INTESTINE GALLSTONE ILEUS 5608 OTHER SPECIFIED INTESTINAL INTESTINAL ADHES W OBSTR INTESTINAL OBSTRUCT NEC 5609 INTESTINAL OBSTRUCT NOS PERFORATION OF INTESTINE 577 DISEASES OF PANCREAS 5770 ACUTE PANCREATITIS 5771 CHRONIC PANCREATITIS 5854 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) 5855 CHRONIC KIDNEY DISEASE, STAGE V 5856 END STAGE RENAL DISEASE ICD-10 Code V56 V560 V561 V562 V563 V5631 V5632 V568 I120 I120 E1343 Description ENCOUNTER FOR DIALYSIS AND DIALYSIS CATHETER CARE RENAL DIALYSIS ENCOUNTER FT/ADJ XTRCORP DIAL CATH FIT/ADJ PERIT DIAL CATH ENCOUNTER FOR ADEQUACY TESTING FOR DIALYSIS HEMODIALYSIS TESTING PERITONEAL DIALYSIS TEST DIALYSIS ENCOUNTER, NEC HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY April 3, 2015 Copyright Health Information Designs, LLC 14

15 E0843 E0943 E1043 K3184 E1143 K315 K50012 K50013 K50014 K50011 K5000 K50018 K50019 K5010 K50111 K50112 K50113 K50114 K50118 K50119 K50814 K50818 K50819 K5080 K50811 K50812 Step 4 (diagnosis of ESRD, CKD, pancreatitis, or severe GI disease) Look back timeframe: 730 days DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY DRUG OR CHEMICAL INDUCED DIABETES MELLITUS WITH NEUROLOGICAL WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY TYPE 1 DIABETES MELLITUS WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY GASTROPARESIS TYPE 2 DIABETES MELLITUS WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY OF DUODENUM CROHN'S DISEASE OF SMALL INTESTINE WITH INTESTINAL CROHN'S DISEASE OF SMALL INTESTINE WITH FISTULA CROHN'S DISEASE OF SMALL INTESTINE WITH ABSCESS CROHN'S DISEASE OF SMALL INTESTINE WITH RECTAL BLEEDING CROHN'S DISEASE OF SMALL INTESTINE WITHOUT CROHN'S DISEASE OF SMALL INTESTINE WITH OTHER COMPLICATION CROHN'S DISEASE OF SMALL INTESTINE WITH UNSPECIFIED CROHN'S DISEASE OF LARGE INTESTINE WITHOUT CROHN'S DISEASE OF LARGE INTESTINE WITH RECTAL BLEEDING CROHN'S DISEASE OF LARGE INTESTINE WITH INTESTINAL CROHN'S DISEASE OF LARGE INTESTINE WITH FISTULA CROHN'S DISEASE OF LARGE INTESTINE WITH ABSCESS CROHN'S DISEASE OF LARGE INTESTINE WITH OTHER COMPLICATION CROHN'S DISEASE OF LARGE INTESTINE WITH UNSPECIFIED CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH ABSCESS CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH OTHER COMPLICATION CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH UNSPECIFIED CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITHOUT CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH RECTAL BLEEDING CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH INTESTINAL April 3, 2015 Copyright Health Information Designs, LLC 15

16 K50813 K5090 K50911 K50912 K50913 K50914 K50919 K50918 K51219 K51218 K51214 K51213 K5120 K51211 K51212 K51319 K51318 K51314 K51313 K51312 K51311 K5130 K51418 K51414 K51413 K51412 K51411 K5140 K51419 K51512 Step 4 (diagnosis of ESRD, CKD, pancreatitis, or severe GI disease) Look back timeframe: 730 days CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH FISTULA CROHN'S DISEASE, UNSPECIFIED, WITHOUT CROHN'S DISEASE, UNSPECIFIED, WITH RECTAL BLEEDING CROHN'S DISEASE, UNSPECIFIED, WITH INTESTINAL CROHN'S DISEASE, UNSPECIFIED, WITH FISTULA CROHN'S DISEASE, UNSPECIFIED, WITH ABSCESS CROHN'S DISEASE, UNSPECIFIED, WITH UNSPECIFIED CROHN'S DISEASE, UNSPECIFIED, WITH OTHER COMPLICATION ULCERATIVE (CHRONIC) PROCTITIS WITH UNSPECIFIED ULCERATIVE (CHRONIC) PROCTITIS WITH OTHER COMPLICATION ULCERATIVE (CHRONIC) PROCTITIS WITH ABSCESS ULCERATIVE (CHRONIC) PROCTITIS WITH FISTULA ULCERATIVE (CHRONIC) PROCTITIS WITHOUT ULCERATIVE (CHRONIC) PROCTITIS WITH RECTAL BLEEDING ULCERATIVE (CHRONIC) PROCTITIS WITH INTESTINAL ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH UNSPECIFIED ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH OTHER COMPLICATION ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH ABSCESS ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH FISTULA ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH INTESTINAL ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH RECTAL BLEEDING ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITHOUT INFLAMMATORY POLYPS OF COLON WITH OTHER COMPLICATION INFLAMMATORY POLYPS OF COLON WITH ABSCESS INFLAMMATORY POLYPS OF COLON WITH FISTULA INFLAMMATORY POLYPS OF COLON WITH INTESTINAL INFLAMMATORY POLYPS OF COLON WITH RECTAL BLEEDING INFLAMMATORY POLYPS OF COLON WITHOUT INFLAMMATORY POLYPS OF COLON WITH UNSPECIFIED LEFT SIDED COLITIS WITH INTESTINAL April 3, 2015 Copyright Health Information Designs, LLC 16

17 K51513 K51514 K51518 K51519 K5150 K51511 K5100 K51018 K51019 K51014 K51013 K51012 K51011 K5180 K51811 K51812 K51813 K51814 K51818 K51819 K5190 K51919 K51911 K51912 K51913 K51914 K51918 K5289 K529 K561 K560 K567 K562 K563 Step 4 (diagnosis of ESRD, CKD, pancreatitis, or severe GI disease) Look back timeframe: 730 days LEFT SIDED COLITIS WITH FISTULA LEFT SIDED COLITIS WITH ABSCESS LEFT SIDED COLITIS WITH OTHER COMPLICATION LEFT SIDED COLITIS WITH UNSPECIFIED LEFT SIDED COLITIS WITHOUT LEFT SIDED COLITIS WITH RECTAL BLEEDING ULCERATIVE (CHRONIC) PANCOLITIS WITHOUT ULCERATIVE (CHRONIC) PANCOLITIS WITH OTHER COMPLICATION ULCERATIVE (CHRONIC) PANCOLITIS WITH UNSPECIFIED ULCERATIVE (CHRONIC) PANCOLITIS WITH ABSCESS ULCERATIVE (CHRONIC) PANCOLITIS WITH FISTULA ULCERATIVE (CHRONIC) PANCOLITIS WITH INTESTINAL ULCERATIVE (CHRONIC) PANCOLITIS WITH RECTAL BLEEDING OTHER ULCERATIVE COLITIS WITHOUT OTHER ULCERATIVE COLITIS WITH RECTAL BLEEDING OTHER ULCERATIVE COLITIS WITH INTESTINAL OTHER ULCERATIVE COLITIS WITH FISTULA OTHER ULCERATIVE COLITIS WITH ABSCESS OTHER ULCERATIVE COLITIS WITH OTHER COMPLICATION OTHER ULCERATIVE COLITIS WITH UNSPECIFIED ULCERATIVE COLITIS, UNSPECIFIED, WITHOUT ULCERATIVE COLITIS, UNSPECIFIED WITH UNSPECIFIED ULCERATIVE COLITIS, UNSPECIFIED WITH RECTAL BLEEDING ULCERATIVE COLITIS, UNSPECIFIED WITH INTESTINAL ULCERATIVE COLITIS, UNSPECIFIED WITH FISTULA ULCERATIVE COLITIS, UNSPECIFIED WITH ABSCESS ULCERATIVE COLITIS, UNSPECIFIED WITH OTHER COMPLICATION OTHER SPECIFIED NONINFECTIVE GASTROENTERITIS AND COLITIS NONINFECTIVE GASTROENTERITIS AND COLITIS, UNSPECIFIED INTUSSUSCEPTION PARALYTIC ILEUS ILEUS, UNSPECIFIED VOLVULUS GALLSTONE ILEUS April 3, 2015 Copyright Health Information Designs, LLC 17

18 K565 K51212 K5669 K51312 K51412 K51512 K51812 K51912 K51012 K50912 K50812 K50112 K5660 K50012 K631 B252 K850 K851 K852 K853 K859 K858 K860 K861 N184 Step 4 (diagnosis of ESRD, CKD, pancreatitis, or severe GI disease) Look back timeframe: 730 days INTESTINAL ADHESIONS [BANDS] WITH (POSTPROCEDURAL) (POSTINFECTION) ULCERATIVE (CHRONIC) PROCTITIS WITH INTESTINAL OTHER INTESTINAL ULCERATIVE (CHRONIC) RECTOSIGMOIDITIS WITH INTESTINAL INFLAMMATORY POLYPS OF COLON WITH INTESTINAL LEFT SIDED COLITIS WITH INTESTINAL OTHER ULCERATIVE COLITIS WITH INTESTINAL ULCERATIVE COLITIS, UNSPECIFIED WITH INTESTINAL ULCERATIVE (CHRONIC) PANCOLITIS WITH INTESTINAL CROHN'S DISEASE, UNSPECIFIED, WITH INTESTINAL CROHN'S DISEASE OF BOTH SMALL AND LARGE INTESTINE WITH INTESTINAL CROHN'S DISEASE OF LARGE INTESTINE WITH INTESTINAL UNSPECIFIED INTESTINAL CROHN'S DISEASE OF SMALL INTESTINE WITH INTESTINAL PERFORATION OF INTESTINE (NONTRAUMATIC) CYTOMEGALOVIRAL PANCREATITIS IDIOPATHIC ACUTE PANCREATITIS BILIARY ACUTE PANCREATITIS ALCOHOL INDUCED ACUTE PANCREATITIS DRUG INDUCED ACUTE PANCREATITIS ACUTE PANCREATITIS, UNSPECIFIED OTHER ACUTE PANCREATITIS ALCOHOL-INDUCED CHRONIC PANCREATITIS OTHER CHRONIC PANCREATITIS CHRONIC KIDNEY DISEASE, STAGE 4 (SEVERE) N185 CHRONIC KIDNEY DISEASE, STAGE 5 N186 Z4901 Z4902 Z4931 END STAGE RENAL DISEASE ENCOUNTER FOR FITTING AND ADJUSTMENT OF EXTRACORPOREAL DIALYSIS CATHETER ENCOUNTER FOR FITTING AND ADJUSTMENT OF PERITONEAL DIALYSIS CATHETER ENCOUNTER FOR ADEQUACY TESTING FOR HEMODIALYSIS April 3, 2015 Copyright Health Information Designs, LLC 18

19 Z4932 Step 4 (diagnosis of ESRD, CKD, pancreatitis, or severe GI disease) Look back timeframe: 730 days ENCOUNTER FOR ADEQUACY TESTING FOR PERITONEAL DIALYSIS CPT Code Description Step 5 (procedure for ESRD services) Look back timeframe: 730 days ESRD RELATED SERVICES, MONTH ESRD RELATED SERVICES, MONTH ESRD RELATED SERVICES, MONTH ESRD RELATED SERVICES, MONTH ESRD RELATED SERVICES, DAY ESRD RELATED SERVICES, DAY ESRD RELATED SERVICES, DAY ESRD RELATED SERVICES, DAY HEMODIALYSIS, ONE EVALUATION HEMODIALYSIS, REPEATED EVAL HEMODIALYSIS ACCESS STUDY HEMODIALYSIS, INITIAL OR ACUTE (EG, ACUTE RENAL FAILURE OR INTOXICAT; PAT OVER 40 KG HEMODIALYSIS, INITIAL OR ACUTE (EG, ACUTE RENAL FAILURE OR INTOXICAT: PAT KG HEMODIAL, INITIAL OR ACUTE (EG, ACUTE RENAL FAILURE OR INTOXICAT; PAT OVER 40 KG HEMODIAL, INITIAL OR ACUTE (EG, ACUTE RENAL FAILURE OR INTOXICAT; PAT UNDER 10 KG DIALYSIS, ONE EVALUATION DIALYSIS, REPEATED EVAL ESRD SERV, 4 VISITS P MO, < ESRD SERV, 2-3 VSTS P MO, < ESRD SERV, 1 VISIT P MO, < ESRD SERV, 4 VSTS P MO, ESRD SRV 2-3 VSTS P MO, ESRD SRV, 1 VISIT P MO, ESRD SRV, 4 VSTS P MO, ESRD SRV 2-3 VSTS P MO ESRD SERV, 1 VST P MO, ESRD SRV, 4 VISITS P MO, ESRD SRV, 2-3 VSTS P MO, 20+ April 3, 2015 Copyright Health Information Designs, LLC 19

20 CPT Code Description Step 5 (procedure for ESRD services) Look back timeframe: 730 days ESRD SERV, 1 VISIT P MO, ESRD HOME PT, SERV P MO, < ESRD HOME PT SERV P MO, ESRD HOME PT SERV P MO ESRD HOME PT, SERV P MO, ESRD HOME PT SERV P DAY, < ESRD HOME PT SRV P DAY, ESRD HOME PT SRV P DAY ESRD HOME PT SERV P DAY, PERITONEAL DIALYSIS FOR CHRONIC RENAL FAILURE; PATIENT MORE THAN 40 KG PERITONEAL DIALYSIS FOR CHRONIC RENAL FAILURE; PATIENT KG PERITONEAL DIALYSIS FOR CHRONIC RENAL FAILURE; PATIENT KG PERITONEAL DIALYSIS FOR CHRONIC RENAL FAILURE; PATIENT UNDER 10 KG PERITONEAL DIALYSIS FOR (ESRD), MAINT STABI COND, HOSP/OTHER FACIL PER SET; MORE 40 KG PERITONEAL DIALYSIS FOR (ESRD),MAINT STABL COND,HOSP/OTHER FAC PER SET;PATIENT KG PERITONEAL DIALYSIS FOR (ESRD),MAINT STABI COND, HOSP/OTHER FAC PER SET;PATIENT KG PERITONEAL DIALYSIS FOR (ESRD),MAINT STABI COND,HOSP/OTHER FAC PER SET;PATIENT UNDER 10K DIALYSIS TRAINING, COMPLETE HEMODIALYSIS TRAINING AND/OR COUNSELING HOME HEMODIALYSIS CARE, OUTPAT, SERV PROVID BY PHYSI RESPONS FOR TOTAL CARE PERITONEAL DIALYSIS TRAINING AND/OR COUNSELING (MEDICARE ONLY) DIALYSIS TRAINING, INCOMPL SUPERVISION OF CHRONIC AMBPERITONEAL DIAL (CAPD),HOME/OUT- PATIENT,MONTHLY April 3, 2015 Copyright Health Information Designs, LLC 20

21 Step 6 (procedure for HbA1c test) Required procedure: 1 Look back timeframe: 180 days CPT Code Description GLYCOSYLATED HEMOGLOBIN TEST GLYCOSYLATED HB, HOME DEVICE Step 8 (history of exenatide) Required quantity: 1 Look back timeframe: 365 days Label Name GCN BYETTA 5 MCG DOSE PEN INJ BYETTA 10 MCG DOSE PEN INJ April 3, 2015 Copyright Health Information Designs, LLC 21

22 Clinical Edit Criteria References 1. Byetta [package insert]. San Diego, CA: Amylin Pharmaceuticals, Inc. Available at Accessed on October 25, ICD-9-CM Diagnosis Codes Available at Accessed on April 3, ICD-10-CM Diagnosis Codes Available at Accessed on April 3, American Medical Association data files ICD-9-CM Diagnosis Codes. Available at 5. American Medical Association data files ICD-10-CM Diagnosis Codes. Available at April 3, 2015 Copyright Health Information Designs, LLC 22

23 Publication History The Publication History records the publication iterations and revisions to this document. Notes for the most current revision are also provided in the Revision Notes on the first page of this document. Publication Date Notes 01/31/2011 Initial publication and posting to website 03/05/2012 Added a new section to specify the drugs requiring prior authorization In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the diagnosis codes pertinent to steps 2 and 4 of the logic diagram In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the drug names and GCNs pertinent to steps 3 and 8 of the logic diagram In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the procedure codes pertinent to steps 5 and 6 of the logic diagram 04/03/2015 Updated to include ICD-10s April 3, 2015 Copyright Health Information Designs, LLC 23