Flexeril/Amrix (Cyclobenzaprine)
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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); 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 Added a new section to specify the drugs requiring prior authorization In the Clinical Edit Criteria Logic and Clinical Edit Criteria Logic Diagram sections, modified the No action to read Go to 5 In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the diagnosis codes pertinent to steps 3 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 1, 2, and 5 of the logic diagram Added Step 5 in all sections to look for a history of a monoamine oxidase inhibitor in the last 14 days October 17, 2011 Copyright 2011 Health Information Designs, LLC 1
2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 10 MG TABLET FEXMID 7.5 MG TABLET October 17, 2011 Copyright 2011 Health Information Designs, LLC 2
3 Clinical Edit Criteria Logic 1. Is the days supply greater than (>) 30 days for the current request and a cyclobenzaprine claim in the last 60 days? [ ] Yes (Go to #2) [ ] No (Go to #3) 2. Does the client have a history of 2 cyclobenzaprine claims in the last 60 days with a combined days supply of greater than (>) 30 days? [ ] Yes (Deny) [ ] No (Go to #3) 3. Does the client have a diagnosis of acute myocardial infarction in the last 180 days? [ ] Yes (Deny) [ ] No (Go to #4) 4. Does the client have a diagnosis of cardiac conditions (cardiac arrhythmias, heart block, congenital long QT syndrome, torsade de points), hyperthyroidism, or heart failure in the last 730 days? [ ] Yes (Deny) [ ] No (Go to #5) 5. Does the client have a history of a monoamine oxidase inhibitor (MAOI) in the last 14 days? [ ] Yes (Deny) [ ] No (Approve 30 days) October 17, 2011 Copyright 2011 Health Information Designs, LLC 3
4 Clinical Edit Criteria Logic Diagram Step 1 Step 2 Is the days supply > 30 days for the current request and a cyclobenzaprine claim in the last 60 days? Yes Does the client have a history of 2 cyclobenzaprine claims in the last 60 days with a combined days supply of greater than 30 days? Yes Deny Request No No Step 3 Does the client have a diagnosis of acute myocardial infarction in the last 180 days? Yes Deny Request No Step 4 Does the client have a diagnosis of cardiac conditions (cardiac arrythmias, heart block, congenital long QT syndrome, torsade de points), hyperthyroidism, or heart failure in the last 730 days? Yes Deny Request No Step 5 Does the client have a history of a monoamine oxidase inhibitor (MAOI) in the last 14 days? Yes Deny Request No Approve Request (30 days) October 17, 2011 Copyright 2011 Health Information Designs, LLC 4
5 Clinical Edit Criteria Supporting Tables Step 1 (days supply greater than 30 days for the current request and a cyclobenzaprine claim) Required quantity: 1 plus incoming request Look back timeframe: 60 days Label Name GCN AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 10 MG TABLET FEXMID 7.5 MG TABLET Label Name Step 2 (two cyclobenzaprine claims with a combined days supply of more than 30 days) Required quantity: 2 Look back timeframe: 60 days GCN AMRIX ER 15 MG CAPSULE AMRIX ER 30 MG CAPSULE CYCLOBENZAPRINE 5 MG TABLET CYCLOBENZAPRINE 10 MG TABLET FEXMID 7.5 MG TABLET Step 3 (diagnosis of acute myocardial infarction) Required diagnosis: 1 Look back timeframe: 180 days ICD-9 Code Description 410 ACUTE MYOCARDIAL INFARCTION 4100 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL AMI ANTEROLATERAL,UNSPEC AMI ANTEROLATERAL, INIT AMI ANTEROLATERAL,SUBSEQ 4101 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL AMI ANTERIOR WALL,UNSPEC October 17, 2011 Copyright 2011 Health Information Designs, LLC 5
6 Step 3 (diagnosis of acute myocardial infarction) Required diagnosis: 1 Look back timeframe: 180 days ICD-9 Code Description AMI ANTERIOR WALL, INIT AMI ANTERIOR WALL,SUBSEQ 4102 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL AMI INFEROLATERAL,UNSPEC AMI INFEROLATERAL, INIT AMI INFEROLATERAL,SUBSEQ 4103 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL AMI INFEROPOST, UNSPEC AMI INFEROPOST, INITIAL AMI INFEROPOST, SUBSEQ 4104 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL AMI INFERIOR WALL,UNSPEC AMI INFERIOR WALL, INIT AMI INFERIOR WALL,SUBSEQ 4105 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL AMI LATERAL NEC, UNSPEC AMI LATERAL NEC, INITIAL AMI LATERAL NEC, SUBSEQ 4106 TRUE POSTERIOR WALL INFARCTION TRUE POST INFARCT,UNSPEC TRUE POST INFARCT, INIT TRUE POST INFARCT,SUBSEQ 4107 SUBENDOCARDIAL INFARCTION SUBENDO INFARCT, UNSPEC SUBENDO INFARCT, INITIAL SUBENDO INFARCT, SUBSEQ 4108 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES AMI NEC, UNSPECIFIED AMI NEC, INITIAL AMI NEC, SUBSEQUENT 4109 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE AMI NOS, UNSPECIFIED AMI NOS, INITIAL AMI NOS, SUBSEQUENT October 17, 2011 Copyright 2011 Health Information Designs, LLC 6
7 Step 4 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 242 THYROTOXICOSIS WITH OR WITHOUT GOITER 2420 TOXIC DIFFUSE GOITER TOX DIF GOITER NO CRISIS TOX DIF GOITER W CRISIS 2421 TOXIC UNINODULAR GOITER TOX UNINOD GOIT NO CRIS TOX UNINOD GOIT W CRISIS 2422 TOXIC MULTINODULAR GOITER TOX MULTNOD GOIT NO CRIS TOX MULTNOD GOIT W CRIS 2423 TOXIC NODULAR GOITER UNSPECIFIED TYPE TOX NOD GOITER NO CRISIS TOX NOD GOITER W CRISIS 2424 THYROTOXICOSIS FROM ECTOPIC THYROID NODULE THYROTOX-ECT NOD NO CRIS THYROTOX-ECT NOD W CRIS 2428 THYROTOXICOSIS OF OTHER SPECIFIED ORIGIN THYRTOX ORIG NEC NO CRIS THYROTOX ORIG NEC W CRIS 2429 THYROTOXICOSIS WITHOUT MENTION OF GOITER OR OTHER CAUSE THYROTOX NOS NO CRISIS THYROTOX NOS W CRISIS 426 CONDUCTION DISORDERS 4260 ATRIOVENT BLOCK COMPLETE 4261 ATRIOVENTRICULAR BLOCK OTHER AND UNSPECIFIED ATRIOVENT BLOCK NOS ATRIOVENT BLOCK-1ST DEGR ATRIOVEN BLOCK-MOBITZ II AV BLOCK-2ND DEGREE NEC 4262 LEFT BB HEMIBLOCK 4263 LEFT BB BLOCK NEC 4264 RT BUNDLE BRANCH BLOCK 4265 BUNDLE BRANCH BLOCK OTHER AND UNSPECIFIED BUNDLE BRANCH BLOCK NOS RT BBB/LFT POST FASC BLK RT BBB/LFT ANT FASC BLK October 17, 2011 Copyright 2011 Health Information Designs, LLC 7
8 Step 4 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description BILAT BB BLOCK NEC TRIFASCICULAR BLOCK 4266 OTHER HEART BLOCK 4267 ANOMALOUS AV EXCITATION 4268 OTHER SPECIFIED CONDUCTION DISORDERS LOWN-GANONG-LEVINE SYND LONG QT SYNDROME CONDUCTION DISORDER NEC 4269 CONDUCTION DISORDER NOS 427 CARDIAC DYSRHYTHMIAS 4270 PAROX ATRIAL TACHYCARDIA 4271 PAROX VENTRIC TACHYCARD 4272 PAROX TACHYCARDIA NOS 4273 ATRIAL FIBRILLATION AND FLUTTER ATRIAL FIBRILLATION ATRIAL FLUTTER 4274 VENTRICULAR FIBRILLATION AND FLUTTER VENTRICULAR FIBRILLATION VENTRICULAR FLUTTER 4275 CARDIAC ARREST 4276 PREMATURE BEATS PREMATURE BEATS NOS ATRIAL PREMATURE BEATS PREMATURE BEATS NEC 4278 OTHER SPECIFIED CARDIAC DYSRHYTHMIAS SINOATRIAL NODE DYSFUNCT CARDIAC DYSRHYTHMIAS NEC 4279 CARDIAC DYSRHYTHMIA NOS 428 HEART FAILURE 4280 CONGESTIVE HEART FAILURE, UNSPECIFIED 4281 LEFT HEART FAILURE 4282 SYSTOLIC HEART FAILURE UNSPECIFIED SYSTOLIC HEART FAILURE ACUTE SYSTOLIC HEART FAILURE CHRONIC SYSTOLIC HEART FAILURE ACUTE ON CHRONIC SYSTOLIC HEART FAILURE October 17, 2011 Copyright 2011 Health Information Designs, LLC 8
9 Step 4 (diagnosis of cardiac condition defect, hyperthyroidism, or heart failure) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description 4283 DIASTOLIC HEART FAILURE UNSPECIFIED DIASTOLIC HEART FAILURE ACUTE DIASTOLIC HEART FAILURE CHRONIC DIASTOLIC HEART FAILURE ACUTE ON CHRONIC DIASTOLIC HEART FAILURE 4284 COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 4289 HEART FAILURE NOS 7802 SYNCOPE AND COLLAPSE 7943 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF CARDIOVASCULAR SYSTEM ABN CARDIOVASC STUDY NOS ABNORM ELECTROCARDIOGRAM 9971 SURG COMPL-HEART Step 5 (history of monoamine oxidase inhibitor therapy) Required quantity: 1 Look back timeframe: 14 days Label Name GCN AZILECT 0.5MG TABLET AZILECT 1MG TABLET EMSAM 6MG/24 HOURS PATCH EMSAM 9MG/24 HOURS PATCH EMSAM 12MG/24 HOURS PATCH MARPLAN 10MG TABLET PHENELZINE SULFATE 15MG TABLET SELEGILINE HCL 5MG CAPSULE SELEGILINE HCL 5MG TABLET TRANYLCYPROMINE 10MG TABLET ZYVOX 100MG/5ML SUSPENSION ZYVOX 200MG/100ML IV SOLN ZYVOX 600MG/300ML IV SOLN October 17, 2011 Copyright 2011 Health Information Designs, LLC 9
10 Step 5 (history of monoamine oxidase inhibitor therapy) Required quantity: 1 Look back timeframe: 14 days Label Name GCN ZYVOX 600MG TABLET October 17, 2011 Copyright 2011 Health Information Designs, LLC 10
11 Clinical Edit Criteria References 1. Gold Standard. Cyclobenzaprine monograph. Tampa, FL: Clinical pharmacology. October 7, Available at: benzaprine. Accessed on October 12, October 17, 2011 Copyright 2011 Health Information Designs, LLC 11
12 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 10/17/2011 Added a new section to specify the drugs requiring prior authorization In the Clinical Edit Criteria Logic and Clinical Edit Criteria Logic Diagram sections, modified the No action to read Go to 5 In the Clinical Edit Criteria Supporting Tables section, revised tables to specify the diagnosis codes pertinent to steps 3 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 1, 2, and 5 of the logic diagram Added Step 5 in all sections to look for a history of a monoamine oxidase inhibitor in the last 14 days October 17, 2011 Copyright 2011 Health Information Designs, LLC 12
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