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 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 te: Click the hyperlink to navigate directly to that section. Revision tes Added Modafinil 100mg and 200 mg tablets to table of drugs requiring prior authorization October 26, 2012 Copyright 2012 Health Information Designs, LLC 1
2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN MODAFINIL 100 MG TABLET MODAFINIL 200 MG TABLET PROVIGIL 100 MG TABLET PROVIGIL 200 MG TABLET October 26, 2012 Copyright 2012 Health Information Designs, LLC 2
3 Clinical Edit Criteria Logic 1. Is the client greater than or equal to ( ) 16 years of age? [ ] (Go to #2) [ ] (Deny) 2. Does the client have a diagnosis of Narcolepsy in the last 1095 days? [ ] (Approve 365 days) [ ] (Go to #3) 3. Does the client have a diagnosis of Shift Work Sleep Disorder in the last 730 days? [ ] (Approve 365 days) [ ] (Go to #4) 4. Does the client have a diagnosis of Obstructive Sleep Apnea in the last 730 days? [ ] (Go to #5) [ ] (Deny) 5. Does the client have a procedure code for CPAP or BiPAP in the last 730 days? [ ] (Approve 365 days) [ ] (Deny) October 26, 2012 Copyright 2012 Health Information Designs, LLC 3
4 Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 Is the client 16 years of age? Does the client have a diagnosis of Narcolepsy in the last 1095 days? Does the client have a diagnosis of Shift Work Sleep Disorder in the last 730 days? Approve (365 days) Step 4 Deny Request Approve (365 days) Does the client have a diagnosis of Obstructive Sleep Apnea in the last 730 days? Deny Request Step 5 Approve (365 days) Does the client have a procedure code for CPAP or BiPAP in the last 730 days? Deny Request October 26, 2012 Copyright 2012 Health Information Designs, LLC 4
5 Clinical Edit Criteria Supporting Tables Step 2 (diagnosis of Narcolepsy) Required diagnosis: 1 Look back timeframe: 1095 days ICD-9 Code Description NARCOLEPSY,WITHOUT CATAPLEXY NARCOLEPSY,WITH CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE, WITHOUT CATAPLEXY NARCOLEPSY IN CONDITIONS CLASSIFIED ELSEWHERE, WITH CATAPLEXY Step 3 (diagnosis of Shift Work Sleep Disorder) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description CIRCADIAN RHYTHM SLEEP DISORDER, OF NON ORGANIC CIRCADIAN RHYTHM SLEEP DISORDER, SHIFT WORK TYPE Step 4 (diagnosis of Obstructive Sleep Apnea) Required diagnosis: 1 Look back timeframe: 730 days ICD-9 Code Description OBSTRUCTIVE SLEEP APNEA (ADULT) INSOMNIA WITH SLEEP APNEA UNSPECIFIED HYPERSOMNIA WITH SLEEP APNEA UNSPECIFIED UNSPECIFIED SLEEP APNEA Step 5 (procedure code for CPAP or BiPAP) Required procedure: 1 Look back timeframe: 730 days CPT Code Description 9390 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) CPAP INITIATION AND MANAGEMENT SLEEP STAGING WITH INITIATION OF CPAP October 26, 2012 Copyright 2012 Health Information Designs, LLC 5
6 Step 5 (procedure code for CPAP or BiPAP) Required procedure: 1 Look back timeframe: 730 days CPT Code E0601 E0470 E0471 E0472 Description CPAP DEVICE CPAP WITH BI-LEVEL FAILURE CPAP WITH BI-LEVEL FAILURE CPAP WITH BI-LEVEL FAILURE October 26, 2012 Copyright 2012 Health Information Designs, LLC 6
7 Clinical Edit Criteria References 1. Provigil (modafinil) prescribing information. Frazer, PA: Cephalon, Inc.; August 17, Available at: Accessed on August 11, Ballon JS, Feifel D. A systematic review of modafinil: Potential clinical uses and mechanisms of action. J Clin Psychiatry 2006;67: Psychopharmacologic Drugs Advisory Committee, United States Food and Drug Administration. March 23, Meeting minutes available at: Accessed on August 11, Gold Standard. Clinical pharmacology: Provigil monograph. Tampa, FL; Accessed on October 14, October 26, 2012 Copyright 2012 Health Information Designs, LLC 7
8 Publication History The Publication History records the publication iterations and revisions to this document. tes for the most current revision are also provided in the Revision tes on the first page of this document. Publication Date tes 01/31/2011 Initial publication and posting to website 04/13/2012 Added a new section to specify the drugs requiring prior authorization In the Clinical Edit Supporting Tables section, revised tables to specify the diagnosis codes pertinent to steps 2, 3 and 4 of the logic diagram In the Clinical Edit Supporting Tables section, revised table to specify the procedure codes pertinent to step 5 of the logic diagram 10/26/2012 Added Modafinil 100mg and 200mg tablets to table of drugs requiring prior authorization October 26, 2012 Copyright 2012 Health Information Designs, LLC 8
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