Lidoderm (Lidocaine) Patch
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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) References: clinical publications and sources relevant to this clinical edit Note: Click the hyperlink to navigate directly to that section. Revision Notes Updated question 3, pages 3-4 Updated Table 3, pages 7-8 February 15, 2018 Copyright 2018 Health Information Designs, LLC 1
2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN LIDOCAINE 5% PATCH LIDODERM 5% PATCH February 15, 2018 Copyright 2018 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 post-herpetic neuralgia or neuropathy in the last 730 days? [] Yes Go to #3 [] No Deny 3. Is the client currently taking a contraindicated drug? [] Yes Deny [] No Go to #4 4. Does the request exceed the maximum recommended daily dose (3 patches per day)? [] Yes Deny [] No Approve Request (365 days) February 15, 2018 Copyright 2018 Health Information Designs, LLC 3
4 Clinical Edit Criteria Logic Diagram Step 1 Is the client 18 years of age? No Deny Request Yes Step 2 Does the client have a diagnosis of postherpetic neuralgia or neuropathy in the last 730 days? No Deny Request Yes Step 3 Has the client had 55 days therapy with a contraindicated drug in the last 60 days? Yes Deny Request No Step 4 Does the request exceed the maximum recommended daily dose? Yes Deny Request No Approve Request (365 days) February 15, 2018 Copyright 2018 Health Information Designs, LLC 4
5 Clinical Edit Criteria Supporting Tables ICD-9 Code Step 2 (diagnosis of neuralgia or neuropathy) Description Required quantity: 1 Look back timeframe: 730 days POSTHERPETIC TRIGEMINAL NEURALGIA POSTHERPETIC POLYNEUROPATHY SECONDARY DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS, UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED 3559 MONONEURITIS OF UNSPECIFIED SITE 3560 HEREDITARY PERIPHERAL NEUROPATHY 3562 HEREDITARY SENSORY NEUROPATHY 3564 IDIOPATHIC PROGRESSIVE POLYNEUROPATHY 3568 OTHER IDIOPATHIC PERIPERAL NEUROPATHY 3569 UNSPECIFIED HEREDITARY AND IDIOPATHIC PERIPHERAL NEUROPATHY ICD-10 Code B0222 B0223 E0840 E0841 E0842 E0843 E0844 Description POSTHERPETIC TRIGEMINAL NEURALGIA POSTHERPETIC POLYNEUROPATHY NEUROPATHY, UNSPECIFIED MONONEUROPATHY POLYNEUROPATHY AUTONOMIC (POLY)NEUROPATHY AMYOTROPHY February 15, 2018 Copyright 2018 Health Information Designs, LLC 5
6 E0849 E08610 E0940 E0941 E0942 E0943 E0944 E0949 E09610 E1340 E1341 E1342 E1343 E1344 E1349 E1140 E1141 E1142 E1143 E1144 E1149 E1040 E1041 E1042 E1043 E1044 Step 2 (diagnosis of neuralgia or neuropathy) Required quantity: 1 Look back timeframe: 730 days DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH OTHER DIABETIC NEUROLOGICAL CONDITION NEUROPATHIC ARTHROPATHY COMPLICATIONS WITH DIABETIC NEUROPATHY, UNSPECIFIED COMPLICATIONS WITH DIABETIC MONONEUROPATHY COMPLICATIONS WITH DIABETIC POLYNEUROPATHY COMPLICATIONS WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY COMPLICATIONS WITH DIABETIC AMYOTROPHY COMPLICATIONS WITH OTHER DIABETIC NEUROLOGICAL COMPLICATION DRUG OR CHEMICAL INDUCED DIABETES MELLITUS WITH DIABETIC NEUROPATHIC ARTHROPATHY OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC MONONEUROPATHY OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY OTHER SPECIFIED DIABETES MELLITUS WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY OTHER SPECIFIED DIABETES MELLOITUS WITH DIABETIC AMYOTROPHY OTHER SPECIFIED DIABETES MELLITUS WITH OTHER DIABETIC NEUROLOGICAL COMPLICATION TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED TYPE 2 DIABETES MELLITUS WITH DIABETIC MONONEUROPATHY TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY 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 1 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED TYPE 1 DIABETES MELLITUS WITH DIABETIC MONONEUROPATHY TYPE 1 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY TYPE 1 DIABETES MELLITUS WITH DIABETIC AUTONOMIC (POLY)NEUROPATHY TYPE 1 DIABETES MELLITUS WITH DIABETIC AMYOTROPHY February 15, 2018 Copyright 2018 Health Information Designs, LLC 6
7 E1049 G589 G600 G603 G608 G609 Step 2 (diagnosis of neuralgia or neuropathy) Required quantity: 1 Look back timeframe: 730 days TYPE 1 DIABETES MELLITUS WITH OTHER DIABETIC NEUROLOGICAL COMPLICATION MONONEUROPATHY, UNSPECIFIED HEREDITARY MOTOR AND SENSORY NEUROPATHY IDIOPATHIC PROGRESSIVE NEUROPATHY OTHER HEREDITARY AND IDIOPATHIC NEUROPATHIES HEREDITARY AND IDIOPATHIC NEUROPATHY, UNSPECIFIED Step 3 (claim for a drug not recommended for use with a lidocaine patch) Required days supply: 55 Look back timeframe: 60 days Label Name GCN AMIODARONE 100MG TABLET AMIODARONE 200MG TABLET AMIODARONE 400MG TABLET BETAPACE 120MG TABLET BETAPACE 160MG TABLET BETAPACE 80MG TABLET CORDARONE 200MG TABLET DISOPYRAMIDE 100MG CAPSULE DISOPYRAMIDE 150MG CAPSULE FLECAINIDE ACETATE 100MG TABLET FLECAINIDE ACETATE 150MG TABLET FLECAINIDE ACETATE 50MG TABLET MEXILETINE 150MG CAPSULE MEXILETINE 200MG CAPSULE MEXILETINE 250MG CAPSULE NORPACE 100MG CAPSULE NORPACE 150MG CAPSULE NORPACE CR 100MG CAPSULE NORPACE CR 150MG CAPSULE PACERONE 100MG TABLET PACERONE 200MG TABLET PACERONE 400MG TABLET PROPAFENONE HCL 150MG TABLET PROPAFENONE HCL 225MG TABLET February 15, 2018 Copyright 2018 Health Information Designs, LLC 7
8 Step 3 (claim for a drug not recommended for use with a lidocaine patch) Required days supply: 55 Look back timeframe: 60 days Label Name GCN PROPAFENONE HCL 300MG TABLET PROPAFENONE HCL ER 225MG CAPSULE PROPAFENONE HCL ER 325MG CAPSULE PROPAFENONE HCL ER 425MG CAPSULE QUINIDINE GLUC ER 324MG TABLET QUINIDINE SULF 200MG TABLET QUINIDINE SULF ER 300MG TABLET QUINIDINE SULF ER 300MG TABLET RYTHMOL 225MG TABLET SOTALOL 120MG TABLET SOTALOL 160MG TABLET SOTALOL 240MG TABLET SOTALOL 80MG TABLET TIKOSYN 125MCG CAPSULE TIKOSYN 250MCG CAPSULE TIKOSYN 500MCG CAPSULE February 15, 2018 Copyright 2018 Health Information Designs, LLC 8
9 Clinical Edit Criteria References 1. Clinical Pharmacology [online database]. Tampa, FL: Elsevier/Gold Standard, Inc.; Available at Accessed on December 16, Micromedex [online database]. Available at Accessed on December 16, ICD-9-CM Diagnosis Codes, Volume Available at Accessed on July 31, ICD-10-CM Diagnosis Codes, Volume Available at Accessed on July 31, Lidoderm Prescribing Information. Malvern, PA. Endo Pharmaceuticals, Inc. July Bril V, England J, Franklin GM, et al. Evidence-based guideline: treatment of painful diabetic neuropathy. Report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2011;76(20): Available at Accessed on January 2, Dubinsky RM, Kabbani H, El-Chami Z, et al. Practice parameter: treatment of postherpetic neuralgia. An evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004;63(6): Guideline reaffirmed February Available at Accessed on January 2, Gronseth G, Cruccu G, Alksne J, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008;71(15): Guideline reaffirmed April Available at Accessed on January 2, Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011;17(Suppl 2):1-53. Available at Accessed on January 2, February 15, 2018 Copyright 2018 Health Information Designs, LLC 9
10 10.American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112(4): Available at Accessed on January 2, February 15, 2018 Copyright 2018 Health Information Designs, LLC 10
11 Publication History 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 01/29/2015 Presented to the DUR Board 02/27/2015 Initial publication and posting to website 07/31/2015 Review of ICD-9 and ICD-10 codes 02/15/2018 Updated question 3, pages 3-4 Updated Table 3, pages 7-8 February 15, 2018 Copyright 2018 Health Information Designs, LLC 11
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