Texas Prior Authorization Program Clinical Edit Criteria

Transcription

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 Supporting Tables section, revised table to specify the diagnosis codes pertinent to step 2 of the logic diagram Modified the criteria logic and logic diagram to identify the steps that are executed manually October 13, 2011 Copyright 2011 Health Information Designs, LLC 1

2 Drugs Requiring Prior Authorization Drugs Requiring Prior Authorization Label Name GCN PROPYLTHIOURACIL 50 MG TABLET October 13, 2011 Copyright 2011 Health Information Designs, LLC 2

3 Clinical Edit Criteria Logic 1. Is the client less than or equal ( ) to 18 years of age? [ ] Yes (Go to #2) [ ] No (Approve 365 days) 2. Does the client have a diagnosis of pregnancy in the past 310 days? [ ] Yes (Approve 310 days) [ ] No (Go to #3) 3. Manual step Does the client have an allergy to methimazole in the last 180 days? [ ] Yes (Approve 180 days) [ ] No (Deny) October 13, 2011 Copyright 2011 Health Information Designs, LLC 3

4 Clinical Edit Criteria Logic Diagram Step 1 Step 2 Step 3 (Manual) Is the client less than or equal to ( ) 18 years of age? Yes Does the client have a diagnosis of pregnancy in the past 310 days? No Does the client have an allergy to methimazole in the last 180 days? No Deny Request No Yes Yes Approve Request (365 days) Approve Request (310 days) Approve Request (180 days) October 13, 2011 Copyright 2011 Health Information Designs, LLC 4

5 Clinical Edit Criteria Supporting Tables Step 2 (diagnosis of pregnancy) Required diagnosis: 1 Look back timeframe: 310 days ICD-9 Code Description RUPTURE DESCEMET MEMBRAN EQUATORIAL STAPHYLOMA THREATEN ABORT-ANTEPART HEM EARLY PG NEC-ANTEPAR HEM EARLY PREG-ANTEPART PLACENTA PREVIA-ANTEPART PLACEN PREV HEM-ANTEPART PREM SEPAR PLAC-ANTEPART COAG DEF HEMORR-ANTEPART ANTEPART HEM NEC-ANTEPAR ANTEPART HEM NOS-ANTEPAR ESSEN HYPERTEN PREG-UNSP ESSEN HYPERTEN-ANTEPART RENAL HYPERTEN PREG-UNSP RENAL HYPERTEN-ANTEPART TRANS HYPERTEN PREG-UNSP TRANS HYPERTEN-ANTEPART MILD/NOS PREECLAMP-UNSP MILD/NOS PREECLAMP-ANTEP SEVERE PREECLAMP-UNSPEC SEV PREECLAMP-ANTEPARTUM ECLAMPSIA-UNSPECIFIED ECLAMPSIA-ANTEPARTUM TOX W OLD HYPERTEN-UNSP TOX W OLD HYPER-ANTEPART HYPERTEN PREG NOS-UNSPEC HYPERTENS NOS-ANTEPARTUM 6430 MILD HYPEREMESIS GRAVIDARUM MILD HYPEREMESIS-ANTEPAR HYPEREM W METAB DIS-UNSP HYPEREM W METAB-ANTEPART LATE VOMIT OF PREG-UNSP LATE VOMIT PREG-ANTEPART VOMIT COMPL PREG-UNSPEC October 13, 2011 Copyright 2011 Health Information Designs, LLC 5

6 ICD-9 Code Description Step 2 (diagnosis of pregnancy) Required diagnosis: 1 Look back timeframe: 310 days VOMIT COMPL PREG-ANTEPAR VOMIT OF PREG NOS-UNSPEC VOMIT OF PG NOS-ANTEPART THREAT PREM LABOR-UNSPEC THRT PREM LABOR-ANTEPART THREAT LABOR NEC-UNSPEC THREAT LABOR NEC-ANTEPAR POST TERM PREG-ANTEPAR PROLONGED PREG-ANTEPAR PAPYRACEOUS FET-ANTEPAR EDEMA IN PREG-UNSPEC EDEMA IN PREG-ANTEPARTUM RENAL DIS PREG NOS-UNSP RENAL DIS NOS-ANTEPARTUM RECURRENT PREGNANCY LOSS, UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE RECURRENT PREGNANCY LOSS, ANTEPARTUM CONDITION OR COMPLICATION NEURITIS OF PREG-UNSPEC NEURITIS OF PREG-ANTEPAR BACTERIURIA PREG-UNSPEC ASY BACTERIURIA-ANTEPART GU INFECT IN PREG-UNSPEC GU INFECTION-ANTEPARTUM LIVER DIS IN PREG-UNSPEC LIVER DISORDER-ANTEPART PREG COMPL NEC-UNSPEC PREG COMPL NEC-ANTEPART PREG COMPL NOS-UNSPEC PREG COMPL NOS-ANTEPART SYPHILIS IN PREG-UNSPEC SYPHILIS-ANTEPARTUM GONORRHEA IN PREG-UNSPEC GONORRHEA-ANTEPARTUM OTHER VD IN PREG-UNSPEC OTHER VD-ANTEPARTUM TB IN PREG-UNSPECIFIED TUBERCULOSIS-ANTEPARTUM MALARIA IN PREG-UNSPEC MALARIA-ANTEPARTUM October 13, 2011 Copyright 2011 Health Information Designs, LLC 6

7 ICD-9 Code Description RUBELLA IN PREG-UNSPEC RUBELLA-ANTEPARTUM OTH VIRUS IN PREG-UNSPEC OTH VIRAL DIS-ANTEPARTUM INF DIS IN PREG NEC-UNSP INFECT DIS NEC-ANTEPART INFECT IN PREG NOS-UNSP INFECT NOS-ANTEPARTUM DIABETES IN PREG-UNSPEC DIABETES-ANTEPARTUM Step 2 (diagnosis of pregnancy) Required diagnosis: 1 Look back timeframe: 310 days THYROID DYSFUN PREG-UNSP THYROID DYSFUNC-ANTEPART ANEMIA IN PREG-UNSPEC ANEMIA-ANTEPARTUM DRUG DEPEND PREG-UNSPEC DRUG DEPENDENCE-ANTEPART MENTAL DIS PREG-UNSPEC MENTAL DISORDER-ANTEPART CONGEN CV DIS PREG-UNSP CONGEN CV DIS-ANTEPARTUM CV DIS NEC PREG-UNSPEC CV DIS NEC-ANTEPARTUM BONE DISORD IN PREG-UNSP BONE DISORDER-ANTEPARTUM ABN GLUCOSE IN PREG-UNSP ABN GLUCOSE-ANTEPARTUM OTH CURR COND PREG-UNSP OTH CURR COND-ANTEPARTUM TOBACCO USE DISORDER COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE TOBACCO USE DISORDER COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, ANTEPARTUM CONDITION OR COMPLICATION OBESITY COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM,UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE OBESITY COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, ANTEPARTUM CONDITION OR COMPLICATION BARIATRIC SURGERY STATUS COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE October 13, 2011 Copyright 2011 Health Information Designs, LLC 7

8 ICD-9 Code Description Step 2 (diagnosis of pregnancy) Required diagnosis: 1 Look back timeframe: 310 days BARIATRIC SURGERY STATUS COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, ANTEPARTUM CONDITION OR COMPLICATION COAGULATION DEFECTS COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE COAGULATION DEFECTS COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, ANTEPARTUM CONDITION OR COMPLICATION EPILEPSY COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE EPILEPSY COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM, ANTEPARTUM CONDITION OR COMPLICATION SPOTTING COMPLICATING PREGNANCY, UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE SPOTTING COMPLICATING PREGNANCY, ANTEPARTUM CONDITION OR COMPLICATION UTERINE SIZE DATE DISCREPANCY, UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE UTERINE SIZE DATE DISCREPANCY, ANTEPARTUM CONDITION OR COMPLICATION CERVICAL SHORTENING, UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE CERVICAL SHORTENING, ANTEPARTUM CONDITION OR COMPLICATION 651 MULTIPLE GESTATION TWIN PREGNANCY-ANTEPART TRIPLET PREG-ANTEPARTUM QUADRUPLET PREG-ANTEPART TWINS W FETAL LOSS-ANTE TRIPLETS W FET LOSS-ANTE QUADS W FETAL LOSS-ANTE MULTIPLE GESTATION FOLLOWING (ELECTIVE) FETAL REDUCTION, ANTEPARTUM CONDITION OR COMPLICATION UNSTABLE LIE-ANTEPARTUM 654 ABNORMALITY OF ORGANS AND SOFT TISSUES OF PELVIS KNOWN OR SUSPECTED FETAL ABNORMALITY AFFECTING MANAGEMENT 655 OF MOTHER FETAL CNS MALFOR-ANTEPAR FET CHROMO ABN-ANTEPART FAMIL HERED DIS-ANTEPART FET DAMG D/T DIS-ANTEPAR FET DAMG D/T DRUG-ANTEPA RADIAT FET DAMAG-ANTEPAR October 13, 2011 Copyright 2011 Health Information Designs, LLC 8

9 ICD-9 Code Description Step 2 (diagnosis of pregnancy) Required diagnosis: 1 Look back timeframe: 310 days DEC FETAL MOVMT ANTEPART FETAL ABNORM NEC-ANTEPAR FETAL ABNORM NOS-ANTEPAR OTHER KNOWN OR SUSPECTED FETAL AND PLACENTAL PROBLEMS 656 AFFECTING MANAGEMENT OF MOTHER POLYHYDRAMNIOS-ANTEPART OLIGOHYDRAMNIOS-ANTEPAR ELDERLY MULTIGRAVD-ANTEP ABN FTL HRT RATE/RHY-ANT VARIC VEIN LEG-ANTEPART VARICOSE VULVA-ANTEPART THROMBOPHLEBIT-ANTEPART FETAL HEMATOLOGIC CONDITIONS, ANTEPARTUM CONDITION OR COMPLICATION FETAL CONJOINED TWINS, ANTEPARTUM CONDITION OR COMPLICATION MATERNAL COMPLICATIONS FROM IN UTERO PROCEDURE, ANTEPARTUM CONDITION OR COMPLICATION FETAL COMPLICATIONS FROM IN UTERO PROCEDURES, ANTEPARTUM CONDITION OR COMPLICATION V23 SUPERVISION OF HIGH-RISK PREGNANCY V230 PREG W HX OF INFERTILITY V231 PREG W HX-TROPHOBLAS DIS V232 PREG W HX OF ABORTION V233 GRAND MULTIPARITY V234 PREG W POOR OBSTETRIC HX V235 PREG W POOR REPRODUCT HX V237 INSUFFICNT PRENATAL CARE V238 SUPERVISION OF OTHER HIGH-RISK PREGNANCY V239 SUPRV HIGH-RISK PREG NOS V241 POSTPART CARE-LACTATION V2341 PREGNANCY WITH HISTORY OF PRE-TERM LABOR V2349 PREGNANCY WITH OTHER POOR OBSTETRIC HISTORY V2381 SUPRV ELDERLY PRIMIGRAV V2382 SUPRV ELDERLY MULTIGRAV V2383 SUPRV YOUNG PRIMIGRAVIDA V2384 SUPRV YOUNG MULTIGRAVIDA V2385 PREGNANCY RESULTING FROM ASSISTED REPRODUCTIVE TECHNOLOGY PREGNANCY WITH HISTORY OF IN UTERO PROCEDURE DURING PREVIOUS V2386 PREGNANCY V2389 SUPRV HIGH-RISK PREG NEC October 13, 2011 Copyright 2011 Health Information Designs, LLC 9

10 Clinical Edit Criteria References 1. Klasko RK, editor: DRUGDEX System (electronic version). Greenwood Village, CO: Thomson Micromedex. Available at Accessed on October 7, Drug Facts and Comparisons. Facts and Comparisons 4.0 [online database]. St. Louis, MO: Wolters Kluwer Health, Inc., Available at Accessed on October 7, U.S. Department of Health and Human Services, U.S. Food and Drug Administration. -induced liver failure. FDA Alert. June 4, Available at entsandproviders/drugsafetyinformationforheathcareprofessionals/ucm htm. Accessed on October 7, AHFS Drug Information 2009 [online book]. Jackson, WY: Teton Data Systems, Version 6.1.0, Based on: McEvoy GK, editor. AHFS drug information Bethesda, MD: American Society of Health-System Pharmacists Ozenirler S, Tuncer C, Boztepe U, et al. -induced hepatic damage. Ann Pharmacother.1996; 30: Reddy CM. and hepatitis: A case report. J Nat Med Assoc 1979; 71: Ruiz JK, Rossi GV, Vallejos HA, et al. Fulminant hepatic failure associated with propylthiouracil. Ann Pharmacother. 2003; 37: Woeber KA. Methimazole-induced hepatotoxicity. Endocrine Practice. 2002; 8(3): Rivkees SA, Mattison DR. Ending propylthiouracil-induced liver failure in children. N Engl J Med 2009; 360:1575. October 13, 2011 Copyright 2011 Health Information Designs, LLC 10

11 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 03/09/2011 Initial publication and posting to website 10/13/2011 Added a new section to specify the drugs requiring prior authorization In the Clinical Edit Supporting Tables section, revised table to specify the diagnosis codes pertinent to step 2 of the logic diagram Modified the criteria logic and logic diagram to identify the steps that are executed manually October 13, 2011 Copyright 2011 Health Information Designs, LLC 11