Texas Prior Authorization Program Clinical Edit Criteria
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1 Texas Prior Authorization Program Clinical Edit Criteria Drug/Drug Class Clinical Edit Information Included in this Document - Oral 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 - Injectable 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. October 25, 2013 Copyright Health Information Designs, LLC 1
2 Revision Notes Changed DM to diabetes insipidus in step 3 of the clinical edit criteria logic and the logic diagram for Oral October 25, 2013 Copyright Health Information Designs, LLC 2
3 , Oral Oral Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN DDAVP 0.1 MG TABLET DDAVP 0.2 MG TABLET DESMOPRESSIN ACETATE 0.1 MG TB DESMOPRESSIN ACETATE 0.2 MG TB October 25, 2013 Copyright Health Information Designs, LLC 3
4 , Oral Oral Clinical Edit Criteria Logic 1. Does the client have a diagnosis of severe renal impairment in the last 365 days? [ ] (Deny) [ ] No (Go to #2) 2. Does the client have a diagnosis of hyponatremia in the last 730 days? [ ] (Deny) [ ] No (Go to #3) 3. Does the client have a diagnosis of primary nocturnal enuresis or diabetes insipidus in the last 730 days? [ ] (Go to #4) [ ] No (Deny) 4. Is the dose requested less than or equal to ( ) 0.8mg per day? [ ] (Approve 365 days) [ ] No (Deny) October 25, 2013 Copyright Health Information Designs, LLC 4
5 , Oral Oral Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Does the client have a diagnosis of severe renal impairment in the last 365 days? No Does the client have a diagnosis of hyponatremia in the last 730 days? No Does the client have a diagnosis of primary nocturnal enuresis or diabetes insipidus in the last 730 days? No Deny Request Step 4 Deny Request Deny Request Is the dose requested No 0.8 mg per day? Deny Request Approve Request (365 days) October 25, 2013 Copyright Health Information Designs, LLC 5
6 , Oral Oral Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of severe renal impairment) Required diagnosis: 1 Look back timeframe: 365 days ICD-9 Code Description HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 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 5804 AC RAPIDLY PROGR NEPHRIT 5824 CHR RAPID PROGR NEPHRIT 5834 RAPIDLY PROG NEPHRIT NOS 5854 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED. 587 RENAL SCLEROSIS NOS V560 RENAL DIALYSIS ENCOUNTER V561 FT/ADJ XTRCORP DIAL CATH V562 FIT/ADJ PERIT DIAL CATH V5631 HEMODIALYSIS TESTING V5632 PERITONEAL DIALYSIS TEST V568 DIALYSIS ENCOUNTER, NEC Step 2 (diagnosis of hyponatremia) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 2761 HYPOSMOLALITY October 25, 2013 Copyright Health Information Designs, LLC 6
7 , Oral Step 3 (diagnosis of primary nocturnal enuresis or DM) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 2535 DIABETES INSIPIDUS URINARY INCONTINENCE NOS URGE INCONTINENCE STRESS INCONTINENCE MALE MIXED INCONTINENCE INCONTNCE WO SENSR AWARE POST-VOID DRIBBLING NOCTURNAL ENURESIS CONTINUOUS LEAKAGE OVERFLOW INCONTINENCE OTH URINRY INCONTINENCE October 25, 2013 Copyright Health Information Designs, LLC 7
8 , Injectable Injectable Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN DDAVP 4 MCG/ML AMPUL DDAVP 4 MCG/ML VIAL DESMOPRESSIN AC 4 MCG/ML VL October 25, 2013 Copyright Health Information Designs, LLC 8
9 , Injectable Injectable Clinical Edit Criteria Logic 1. Does the client have a diagnosis of severe renal impairment in the last 365 days? [ ] (Deny) [ ] No (Go to #2) 2. Does the client have a diagnosis of hyponatremia in the last 730 days? [ ] (Deny) [ ] No (Go to #3) 3. Does the client have a diagnosis of diabetes insipidus, hemophilia, or Von Willebrand s disease in the last 730 days? [ ] (Go to #5) [ ] No (Go to #4) 4. Does the client have a history of an anti-hemophilic factors agent in the last 730 days? [ ] (Go to #5) [ ] No (Deny) 5. Is the dose requested less than or equal to ( ) 1 ml per day? [ ] (Approve days) [ ] No (Deny) October 25, 2013 Copyright Health Information Designs, LLC 9
10 , Injectable Injectable Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Step 4 Does the client have a diagnosis of severe renal impairment in the last 365 days? No Does the client have a diagnosis of hyponatremia in the last 730 days? No Does the client have a diagnosis of diabetes insipidus, hemophilia, or Von Willebrand s disease in the last 730 days? No Does the client have a history of an antihemophilic factors agent in the last 730 days? No Step 5 Is the dose requested No Deny Request Deny Request 1.0 ml per day? Deny Request Approve Request (365 days) October 25, 2013 Copyright Health Information Designs, LLC 10
11 , Injectable Injectable Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of severe renal impairment) Required diagnosis: 1 Look back timeframe: 365 days ICD-9 Code Description HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 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 5804 AC RAPIDLY PROGR NEPHRIT 5824 CHR RAPID PROGR NEPHRIT 5834 RAPIDLY PROG NEPHRIT NOS 5854 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED. 587 RENAL SCLEROSIS NOS V560 RENAL DIALYSIS ENCOUNTER V561 FT/ADJ XTRCORP DIAL CATH V562 FIT/ADJ PERIT DIAL CATH V5631 HEMODIALYSIS TESTING V5632 PERITONEAL DIALYSIS TEST V568 DIALYSIS ENCOUNTER, NEC Step 2 (diagnosis of hyponatremia) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 2761 HYPOSMOLALITY October 25, 2013 Copyright Health Information Designs, LLC 11
12 , Injectable Step 3 (diagnosis of diabetes insipidus, hemophilia, or Von Willebrand s disease) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 2535 DIABETES INSIPIDUS 2860 CONG FACTOR VIII DISORDER 2864 VON WILLEBRAND'S DISEASE Step 4 (history of an anti-hemophilic factors agent) Required quantity: 1 Look back timeframe: 730 days Label Name GCN ADVATE UNITS VIAL ADVATE UNITS VIAL ADVATE 801-1,200 UNITS VIAL ADVATE 1,201-1,800 UNITS VIAL ADVATE 1,801-2,400 UNITS VIAL ADVATE 2,400-3,600 UNITS VIAL ALPHANATE UNIT VIAL ALPHANATE UNIT VIAL ALPHANATE 1, UNIT VIAL ALPHANATE 1, UNIT VIAL ALPHANINE SD 500 UNITS VIAL ALPHANINE SD 1,000 UNITS VIAL BEBULIN 200-1,200 UNITS VIAL BENEFIX 250 UNIT KIT BENEFIX 500 UNIT KIT BENEFIX 1,000 UNIT KIT BENEFIX 2,000 UNIT KIT BENEFIX 250 UNIT VIAL BENEFIX 500 UNIT VIAL BENEFIX 1,000 UNIT VIAL FEIBA NF UNIT VIAL FEIBA NF 651-1,200 UNIT VIAL FEIBA NF 1,750-3,250 UNIT VIAL FEIBA VH IMMUNO UNITS FEIBA VH IMMUNO 651-1,200 UNIT FEIBA VH IMMU 1,750-3,250 UNIT HELIXATE FS 250 UNIT VIAL October 25, 2013 Copyright Health Information Designs, LLC 12
13 , Injectable Step 4 (history of an anti-hemophilic factors agent) Required quantity: 1 Look back timeframe: 730 days Label Name GCN HELIXATE FS 500 UNIT VIAL HELIXATE FS 1,000 UNIT VIAL HELIXATE FS 2,000 UNIT VIAL HEMOFIL M UNITS VIAL HEMOFIL M UNITS VIAL HUMATE-P 600 UNIT VWF:RCO HUMATE-P 1,200 UNIT VWF:RCO HUMATE-P 2,400 UNIT VWF:RCO KOATE-DVI 250 UNIT KIT KOATE-DVI 500 UNITS KIT KOATE-DVI 1,000 UNITS KIT KOGENATE FS 250 UNIT VIAL KOGENATE FS 500 UNIT VIAL KOGENATE FS 1,000 UNITS VIAL KOGENATE FS 2,000 UNIT VIAL MONOCLATE-P 250 UNIT KIT MONOCLATE-P 1,000 UNITS KIT MONOCLATE-P 1,500 UNITS KIT MONOCLATE-P 500AHFU KIT PROFILNINE SD 500 UNITS VIAL RECOMBINATE 1,801-2,400 UNIT V RECOMBINATE UNIT VIAL RECOMBINATE UNIT VIAL RECOMBINATE 801-1,240 UNIT VL October 25, 2013 Copyright Health Information Designs, LLC 13
14 Clinical Edit Criteria References 1. Food and Drug Administration (FDA). MedWatch. Available at: Accessed on March 3, acetate (DDAVP ) [official prescribing information]. Bridgewater, NJ: Sanofi-Aventis U.S., LLC. Available at: bl.pdf. Accessed on February 27, October 25, 2013 Copyright Health Information Designs, LLC 14
15 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 05/24/2012 Initial publication and posting to website 10/25/2013 Changed DM to diabetes insipidus in step 3 of the clinical edit criteria logic and the logic diagram for Oral October 25, 2013 Copyright Health Information Designs, LLC 15
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