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 Aldara 5% Cream 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 Zyclara 3.75% Cream 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. July 18, 2012 Copyright 2012 Health Information Designs, LLC 1
2 Revision Notes Initial publication and posting to website July 18, 2012 Copyright 2012 Health Information Designs, LLC 2
3 , Aldara 5% Cream Aldara 5% Cream Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN ALDARA 5% CREAM IMIQUIMOD 5% CREAM PACKET July 18, 2012 Copyright 2012 Health Information Designs, LLC 3
4 , Aldara 5% Cream Aldara 5% Cream Clinical Edit Criteria Logic 1. Does the client have a diagnosis of genital or perianal warts in the last 60 days? [ ] Yes (Go to #2) [ ] No (Go to #3) 2. Is the client greater than or equal to ( ) 12 years of age? [ ] Yes (Approve days) [ ] No (Deny) 3. Is the client greater than or equal to ( ) 18 years of age? [ ] Yes (Go to #4) [ ] No (Deny) 4. Does the client have a diagnosis of actinic keratosis or basal cell carcinoma in the last 60 days? [ ] Yes (Approve days) [ ] No (Deny) July 18, 2012 Copyright 2012 Health Information Designs, LLC 4
5 , Aldara 5% Cream Aldara 5% Cream Clinical Edit Criteria Logic Diagram Step 1 Step 2 Does the client have a diagnosis of genital or perianal warts in the last 60 days? Yes Is the client 12 years of age? Yes Approve (365 days) No No Deny Request Step 3 Step 4 Is the client 18 years of age? Yes Does the client have a diagnosis of actinic keratosis or basal cell carcinoma in the last 60 days? Yes Approve (365 days) No No Deny Request Deny Request July 18, 2012 Copyright 2012 Health Information Designs, LLC 5
6 , Aldara 5% Cream Aldara 5% Cream Clinical Edit Criteria Supporting Tables Step 1 (diagnosis of genital or perianal warts) Required diagnosis: 1 Look back timeframe: 60 days ICD-9 Code Description VIRAL WARTS NOS CONDYLOMA ACUMINATUM PLANTAR WART OTH SPECFD VIRAL WARTS 1730 MALIG NEO SKIN LIP 1731 MALIG NEO SKIN EYELID 1732 MALIG NEO SKIN EAR 1733 MAL NEO SKIN FACE NEC 1734 MAL NEO SCALP/SKIN NECK 1735 MALIG NEO SKIN TRUNK 1736 MALIG NEO SKIN ARM 1737 MALIG NEO SKIN LEG 1738 MALIG NEO SKIN NEC 1739 MALIG NEO SKIN NOS 7020 ACTINIC KERATOSIS 7810 ABN INVOLUN MOVEMENT NEC 7811 SMELL & TASTE DISTURB 7812 ABNORMALITY OF GAIT 7813 LACK OF COORDINATION 7814 TRANSIENT LIMB PARALYSIS 7815 CLUBBING OF FINGERS 7816 MENINGISMUS 7817 TETANY 7818 NEUROLOGIC NEGLECT SYNDROME July 18, 2012 Copyright 2012 Health Information Designs, LLC 6
7 , Aldara 5% Cream Step 4 (diagnosis of actinic keratosis or basal cell carcinoma) Required diagnosis: 1 Look back timeframe: 60 days ICD-9 Code Description 1730 MALIG NEO SKIN LIP 1731 MALIG NEO SKIN EYELID 1732 MALIG NEO SKIN EAR 1733 MAL NEO SKIN FACE NEC 1734 MAL NEO SCALP/SKIN NECK 1735 MALIG NEO SKIN TRUNK 1736 MALIG NEO SKIN ARM 1737 MALIG NEO SKIN LEG 1738 MALIG NEO SKIN NEC 1739 MALIG NEO SKIN NOS 7020 ACTINIC KERATOSIS July 18, 2012 Copyright 2012 Health Information Designs, LLC 7
8 , Zyclara 3.75% Cream Zyclara 3.75% Cream Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN ZYCLARA 3.75% CREAM July 18, 2012 Copyright 2012 Health Information Designs, LLC 8
9 , Zyclara 3.75% Cream Zyclara 3.75% Cream 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 actinic keratosis in the last 60 days? [ ] Yes (Approve days) [ ] No (Deny) July 18, 2012 Copyright 2012 Health Information Designs, LLC 9
10 , Zyclara 3.75% Cream Zyclara 3.75% Cream Clinical Edit Criteria Logic Diagram Step 1 Step 2 Is the client 18 years of age? Yes Does the client have a diagnosis of actinic keratosis in the last 60 days? Yes Approve (365 days) No No Deny Request Deny Request July 18, 2012 Copyright 2012 Health Information Designs, LLC 10
11 , Zyclara 3.75% Cream Zyclara 3.75% Cream Clinical Edit Criteria Supporting Table Step 2 (diagnosis of actinic keratosis) Required diagnosis: 1 Look back timeframe: 60 days ICD-9 Code Description 7020 ACTINIC KERATOSIS July 18, 2012 Copyright 2012 Health Information Designs, LLC 11
12 Clinical Edit Criteria References 1. Aldara [package insert]. Bristol, TN: Graceway Pharmaceuticals, LLC. October MICROMEDEX Health Services. DRUGDEX evaluations: drug evaluation. Available at: Accessed on February 29, Lexi-Comp Drug Information Handbook. drug evaluation. Available at: Accessed on February 29, July 18, 2012 Copyright 2012 Health Information Designs, LLC 12
13 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 07/18/2012 Initial publication and posting to website July 18, 2012 Copyright 2012 Health Information Designs, LLC 13
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