Drugs Requiring Prior Authorization Label Name GCN GABAPENTIN 100 MG CAPSULE 00780 GABAPENTIN 300 MG CAPSULE 00781 GABAPENTIN 400 MG CAPSULE 00782 GABAPENTIN 250 MG/5 ML SOLN 13235 GABAPENTIN 600 MG TABLET 94624 GABAPENTIN 800 MG TABLET 94447 NEURONTIN 100 MG CAPSULE 00780 NEURONTIN 300 MG CAPSULE 00781 NEURONTIN 400 MG CAPSULE 00782 NEURONTIN 250 MG/5 ML SOLN 13235 NEURONTIN 600 MG TABLET 94624 NEURONTIN 800 MG TABLET 94447 Clinical Edit Criteria Logic 1. Is the dose less than or equal to 1,400 mg per day? Yes (Approve 365 Days) No (Go to #2) 2. Does the client have a diagnosis of Chronic Kidney Disease in the last 365 days? Yes (Deny) No (Approve 365 Days)
Clinical Edit Criteria Logic Diagram Step 1: Is the dose less than or equal to 1,400 mg per day? Yes Approve for 365 days No Step 2: Does the client have a diagnosis of Chronic Kidney Disease in the last 365 days? Yes Deny No Approve for 365 Days
Clinical Edit Criteria Supporting Tables ICD-9 Code Description Step 2 (Diagnosis of Chronic Kidney Disease) Required Diagnosis: 1 Look Back Timeframe: 365 Days 403 HYPERTENSIVE CHRONIC KIDNEY DISEASE 4030 MALIGNANT HYPERTENSIVE KIDNEY DISEASE 40300 40301 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH 4031 BENIGN HYPERTENSIVE KIDNEY DISEASE 40310 40311 HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 4039 UNSPECIFIED CHRONIC KIDNEY DISEASE 404 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE 4040 MALIGNANT HYPERTENSIVE HEART AND KIDNEY DISEASE HYPERTENSIVE HEART AND CHRONIC KIDENY DISEASE, MALIGNANT 40400 WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 40401 HYPERTENSIVE HEART AND CHRONIC KIDENY DISEASE, MALIGNANT WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V 40402 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT 40403 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH 4041 BENIGN HYPERTENSIVE HEART AND KIDNEY DISEASE 40410 WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY STAGE I THROUGH STAGE IV, OR UNSPECIFIED WITH 40411 HEART FAILURE AND WITH CHRONIC KIDNEY STAGE I THROUGH STAGE IV, OR UNSPECIFIED 40412 WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY STAGE V OR END STAGE RENAL DISEASE
40413 WITH HEART FAILURE AND WITH CHRONIC KIDNEY STAGE V OR END STAGE RENAL DISEASE 4049 UNSPECIFIED HYPERTENSIVE HEART AND KIDNEY DISEASE 582 CHRONIC 5820 CHR PROLIFERAT NEPHRITIS 5821 CHR MEMBRANOUS NEPHRITIS 5822 CHR MEMBRANOPROLIF NEPHRITIS 5824 CHR RAPID PROGR NEPHRIT 5828 CHRONIC WITH OTHER SPECIFIED PATHOOLOGICAL LESION IN KIDNEY 58281 CHR NEPHRITIS IN OTH DIS 58289 CHR NEPHRITIS NEC 5829 CHR NEPHRITIS NOS 585 CHRONIC RENAL FAILURE 5851 CHRONIC KIDNEY DISEASE, STAGE I 5852 CHRONIC KIDNEY DISEASE, STAGE II (MILD) 5853 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) 5854 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) 5855 CHRONIC KIDNEY DISEASE, STAGE V 5856 END STAGE RENAL DISEASE 5859 CHRONIC KIDNEY DISEASE, UNSPECIFIED ICD-10 Code I120 I129 I130 I1310 I1311 I132 N030 Description HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE WITH STAGE 1 THROUGH STAGE 4 CHRONIC KIDNEY DISEASE, OR UNSPECIFIED CHRONIC KIDNEY DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE AND STAGE 1 THROUGH STAGE 4 CHRONIC KIDNEY DISEASE, OR UNSPECIFIED CHRONIC KIDNEY DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITHOUT HEART FAILURE, WITH STAGE 1 THROUGH STAGE 4 CHRONIC KIDNEY DISEASE, OR UNSPECIFIED CHRONIC KIDNEY DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITHOUT HEART FAILURE, WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE CHRONIC NEPHRITIC SYNDROME WITH MINOR GLOMERULAR ABNORMALITY
N031 N032 N033 N034 N035 N036 N037 N038 N039 CHRONIC NEPHRITIC SYNDROME WITH FOCAL AND SEGMENTAL GLOMERULAR LESIONS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE MEMBRANOUS CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE MESANGIAL PROLIFERATIVE CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE ENDOCAPILLARY PROLIFERATIVE CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE MESANGIOCAPILLARY CHRONIC NEPHRITIC SYNDROME WITH DENSE DEPOSIT DISEASE CHRONIC NEPHRITIC SYNDROME WITH DIFFUSE CRESCENTIC CHRONIC NEPHRITIC SYNDROME WITH OTHER MORPHOLOGIC CHANGES CHRONIC NEPHRITIC SYNDROME WITH UNSPECIFIED MORPHOLOGIC CHANGES N181 CHRONIC KIDNEY DISEASE, STAGE 1 N182 N183 N184 CHRONIC KIDNEY DISEASE, STAGE 2 (MILD) CHRONIC KIDNEY DISEASE, STAGE 3 (MODERATE) CHRONIC KIDNEY DISEASE, STAGE 4 (SEVERE) N185 CHRONIC KIDNEY DISEASE, STAGE 5 N186 N189 END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED References 1. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc., updated January 2011. Available at http://www.clinicalpharmacology.com/?epm=2 1. 2. 2011 ICD-9-CM Diagnosis Codes, Volume 1, 2011. Available at http://www.icd9data.com/. Accessed on August 14, 2011. 3. 2015 ICD-10-CM Diagnosis Codes. 2015. Available at www.icd10data.com. Accessed on April 3, 2015. 4. American Medical Association data files. 2015 ICD-9-CM Diagnosis Codes. Available at www.commerce.ama-assn.org. 5. American Medical Association data files. 2015 ICD-10-CM Diagnosis Codes. Available at www.commerce.ama-assn.org. Publication History Publication Date Notes 04/17/2012 Initial Publication 07/20/ Added ICD-10 Codes Updated Dates