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Icd 9 code for rheumatoid arthritis steroid dependent where to inject steroids

Icd 9 code for rheumatoid arthritis steroid dependent

In those without DM GC use had a 4. In those with DM, GC use was associated with an additional A similar pattern was seen for CV mortality. The adjusted Cox proportional hazards model showed no evidence of multiplicative interaction, but additive interaction indicated a non-significant increased risk. For CV mortality there was no interaction on either scale. GC use was associated with higher mortality rates in people with comorbid DM compared to people without DM, despite apparently reassuring similar relative risks.

Clinicians need to be aware of the higher baseline risk in patients with DM, and consider this when prescribing GCs in patients with RA and comorbid DM. Peer Review reports. Glucocorticoids GC have been widely used as a treatment for RA since their discovery in the s [ 3 ] and continue to be used in around half of patients with RA [ 4 ]. Although GCs have many benefits, they also have risks associated with them, including possible increased risk of CV events and mortality [ 5 , 6 ].

In addition, GCs are known to increase the risk of diabetes mellitus DM [ 7 , 8 ] and are associated with poor glucose control [ 9 ], meaning they may also affect the long-term outcome of DM including CV events and mortality [ 10 , 11 ]. This has not been investigated in patients with RA.

Further, it is not known how the additional burden of DM and then GC therapy influence the cardiovascular and mortality risk in patients with RA. Therefore an important unanswered question is whether GC treatment in RA is associated with worse outcomes in patients with comorbid DM, compared to patients without DM.

As we think that the baseline risk of CV and all-cause mortality for patients with RA and DM will be higher than those with RA only, to investigate the impact of GCs it is appropriate to look at the absolute risks as well as the relative risks. The aims of this study were: 1 to compare the event rates for all-cause mortality and CV mortality, by GC use status and DM status, and 2 to examine whether DM modifies, on either the multiplicative or additive scales, the effect of GCs on all-cause mortality and CV mortality.

For this study, only data from practices that consented to ONS linkage were used if the data met acceptability standards and was up to research standard. Patients entered into the study upon RA diagnosis and participation ended at death, the date the patient left the practice or at the end of the study period. All patients were registered with the practice for a year prior to RA diagnosis, to ensure patients were truly incident cases. Patients with polycystic ovary syndrome PCOS treated with metformin were excluded as it was possible they were incorrectly identified as diabetic because of taking anti-diabetic medication.

Diagnosis of DM was time-varying and could be prior to diagnosis of RA whereby a person would be flagged as diabetic throughout follow-up, or during follow-up whereby a person would be flagged as diabetic from the point of DM diagnosis. Where the diagnosis was made on the basis of two sequential prescriptions, the date of onset was allocated as the date of the second prescription to avoid immortal time bias. Oral GC therapy was identified using product codes from prescription data.

All-cause and CV mortality were identified through linkage to ONS data with date of death and cause of death provided. CV mortality was identified using ICD codes under the circulatory chapter heading as the underlying cause of death. Age at RA diagnosis was calculated using year of birth and year of RA diagnosis.

Gender was given on the CPRD database. Baseline Charlson comorbidity index was determined using an adaption of the index for CPRD data where diseases were identified through Read codes for diagnosis at any point prior to RA diagnosis [ 14 ]. GC use in the year preceding baseline was determined from GC prescriptions prior to baseline.

Prior macrovascular disease was defined as diseases of large blood vessels including myocardial infarction, stroke, peripheral artery disease or amputation [ 15 ] and were identified through Read codes prior to RA diagnosis.

All code lists can be found in Additional file 1. When estimating the effect of both GC exposure and DM status, the presence of interaction was measured on both the multiplicative scale, corresponding to the RR, and on the additive scale, corresponding to the RD.

Interaction on the additive scale can give more meaningful comparisons as it is not dependent on baseline risks [ 16 ]. Multiplicative interaction was assessed via the inclusion of an interaction term in the Cox model. Additive interaction cannot be estimated directly from the Cox model as it depends on the baseline hazard function [ 17 ].

The RERI is equal to 0 if the additive interaction effect is equal to 0. Therefore, if it is statistically significantly different from zero then this is interpreted as a statistically significant difference in the hazard differences between those with and without DM, and indicates the direction of the effect. Departure from 1 indicates a difference in the two groups and it was calculated here in addition to the RERI as it gives an indication of the magnitude of the difference in subgroup absolute effects, unlike the RERI.

Both measures are calculated after the Cox model as a function of the model parameters. Multiple imputation with 57 imputations was used to replace these missing values. The number of imputations was based on the fraction of missing information. Forty-nine patients did not have a Townsend score, however this was not imputed as it was not used in the final models.

The cohort had a mean follow-up of 5. At baseline there were patients with DM, and patients developed DM during follow-up. Across both those with and without DM those who ever used GC were older and had more prior macrovascular disease. During follow-up there were 1, deaths. Mortality rates differed according to the presence of DM and the use of GC therapy. For those with DM, the mortality rate was For those without DM, the mortality rate was Adjustment removed this significant interaction 0.

There were CV deaths during follow-up. The unadjusted and adjusted Cox models showed that DM did not interact with ever GC use on the multiplicative scale, the additive interaction indicated increased risk but was not statistically significant Table 3.

This might seem reassuring at first glance, suggesting the impact of GC therapy in patients with DM is no worse than in patients without DM. However, the RD was notably higher in those with DM compared to those without. The higher baseline mortality rate for those with DM is thus resulting in a greater number of excess deaths despite the slightly lower RR.

The increased absolute hazard for all-cause mortality indicates the greater public health impact of people with RA using GCs if they have DM. This increase is not seen on the multiplicative scale because the comparison made is relative to other patients with DM who have a higher risk of mortality prior to using GCs. Notably, most studies only assess effect modification or interaction on the multiplicative scale, despite recommendations to use both the multiplicative and additive scales [ 16 , 19 ].

Studies have looked at short term diabetic outcomes with GC use, investigating its effects on glucose intolerance or metabolic syndrome in patients with RA [ 8 , 20 ]. The other study aimed to describe the adverse effects of GC treatment in patients with DM, but did not discuss mortality [ 11 ]. We and others have previously shown GC therapy to be associated with higher all-cause mortality rates in patients with RA. This was a large study that used electronic medical records that are a rich source of medical information.

However, there are some limitations with the study. Although we used a validated algorithm to identify patients with RA there could still be some misclassification. Further misclassification may result from medication being based on prescription data rather than dispensing data. However, any differences between prescribed medication and medication dispensed are unlikely to differ by DM status.

To allow examination of interaction a simple model of oral GC exposure was used, therefore it was not possible to examine the impact of GC dose or intramuscular GCs. This study focuses on type 2 DM, as GCs induce insulin resistance similar to type 2 diabetes. Results are likely to be similar with type 1 diabetes, but given the different pathogenetic mechanisms, further work would be required to confirm this. However, there is no measure of disease activity available on CPRD and we would not expect the confounding to differentially affect those with or without DM.

There may be known unmeasured confounding, there were no measures of biologic DMARD use in this study as biologics are only prescribed in secondary care in the UK. This may be important as biologics have been shown to be associated with reduced CVD [ 23 ].

Unfortunately we were not able to use methods to explore unmeasured confounding as most are applied to relative risks rather than additive interaction terms. This study gives an indication that GC therapy may be associated with a higher number of deaths in patients with RA and comorbid type 2 DM. Rheumatologists should consider DM status when prescribing GCs to patients with RA given this potential impact of GC therapy on glucose control and mortality.

The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum. Article Google Scholar. Effects of cortisone acetate and pituitary acth on rheumatoid arthritis, rheumatic fever and certain other conditions - a study in clinical physiology.

Arch Intern Med. Half of U. Arthritis Res Ther. Glucocorticoid dose thresholds associated with all-cause and cardiovascular mortality in rheumatoid arthritis. Arthritis Rheumatol. Glucocorticoids and cardiovascular events in rheumatoid arthritis: a population-based cohort study. Risk of incident diabetes mellitus associated with the dosage and duration of oral glucocorticoid therapy in patients with rheumatoid arthritis.

Glucose tolerance, insulin sensitivity and beta-cell function in patients with rheumatoid arthritis treated with or without low-to-medium dose glucocorticoids. Note: Initial approval will be for a maximum of 3 months. If there is weight loss or the recipient has been able to maintain prior weight loss during this initial period, subsequent prior authorization requests may be approved up to a maximum of 6 months.

For Children: 8. Replacement of calcium in documented calcium deficient patients that require enteral tube feedings of calcium, etc. If a diagnosis is not on the claim, it will be denied. Generic products are available without prior authorization for FDA approved indications 3.

For single source prescription nonsteroidal anti-inflammatory drugs a. At least two 2 generically available products have been given adequate trials and have proven ineffective; b. Documentation of the Drug, the dose and the length of time for each generic tried is included ion the prior authorization form; c.

If serious side effects developed or have a real potential of developing, document them on the prior authorization form. Note: Once Prior Authorization has been approved for a single source product in this class, the drug may be changed to another single source product within the approved time period without a new request.

However, the alternative s must be listed on the original prior authorization form. Documentation of malignant cells testing positive for CD25 expression 2. Significant reduction in tumor size should be seen prior to the fourth 4th course of treatment. Three 3 treatment cycles of 5 days each will be approved initially. Utilizatoin review over calendar years and indicated inappropriate use of ICD-9 in this range.

Authorization requests for use in chronic non-cancer pain for daily dosage exceeding mg: 1. Patient must be at least 18 years old. Patient must not be pregnant. No prior authorization needed if the physician is a Medicaid provider with a specialty in oncology 5. Strength and total daily dosage must be provided.

Documentation of the failure or non-tolerance of at least one other long acting opioid analgesic. The name of the pain specialist must be attached. If being seen by a pain specialist, the name of the pain specialist and the plan of care must be attached. A plan of care for the treatment must be attached. No early refills will be allowed. Authorization requests for patients with pain related to systemic cancer for total daily doses exceeding mg prescribed by non-oncologists: 1.

Diagnosis must be provided. Prior Authorization is required for early refills for dose adjustments, lost or stolen medications. No authorization requirement for over mg per day: 1. Oncologist must provide the pharmacy with the ICD-9 diagnosis. Prior authorization is required for early refills due to dose adjustments, lost or stolen medications. Approval Period: 1. For pain related to cancer, the authorization period will be a maximum of six 6 months.

Systemic anti-KS treatment is not needed. Note on the prior authorization form that no systemic KS treatment is indicated. Systemic treatment would be indicated in such instances of more than ten 10 new KS lesions in the prior month, symptomatic lymphedema, symptomatic pulmonary KS or symptomatic visceral involvement. Submit another B Form with justification if therapy is needed for longer. Patient must have advanced symptomatic prostate cancer, in whom LHRH agonist therapy is not appropriate and who refuse surgical castration, and have one or more of the following: a.

Risk of neurological compromise due to metastases. Ureteral or bladder outlet obstruction due to local encroachment or metastatic disease. Severe bone pain from skeletal metastases persisting on narcotic analgesia. Claims for PPIs will process in the following instances: 1. Quantities for the treatment of heartburn are limited to one 1 tablet per day. SmartPA will verify clinical criteria every three 3 months. Diagnosis of H.

Claims are processed for a maximum of 14 days. Prescription Omeprazole — Recipients younger than 21 years of age with a nasogastric NG tube in two-year medical history. If a recipient has a previous claim history of therapy with another cholinesterase Inhibitor then the prescriber and pharmacy will need to work together to complete an B form and submit it to the ACS PBM PA Desk.

Other conventional agents such as sulfasalazine, mesalamine derivatives, steroids, azathioprine, 6-mercaptopure, or metronidazole are ineffective or are not medically appropriate. Provide the following information on the Request for Medical Authorization B Form : 1 State treatment with methotrexate has not been adequate or effective or is not medically appropriate.

Note: If the infusion is to be done in the home setting, home pharmacy services and supplies related to the infusion of Remicade must be prior authorized. Sedative-Hypnotics Generic temazepam 15mg and 30mg, and generic estazolam shall be tried first. Claims for Ambien CR will process if there is at least a day trial with generic temazepam 15mg or 30mg or generic estazolam in the previous six 6 months then proceed to clinical criteria edits.

Providers may call into the ACS PBM Call Center at for assistance with Ambien CR if the recipient has either developed or has the potential to develop serious side effects to generic temazepam 15mg or 30mg or generic estazolam. Clinical criteria edits will then process. Claims for brand and generic Dalmane and Halcion, Sonata, Doral, Lunesta, Prosom, Restoril require at least a day trial of Ambien CR in order for authorization to be granted; then proceed to clinical criteria edits.

Rozerem allowed without a trial of temazepam or estazolam for the following populations:. The clinical criteria are applied to all sedative-hypnotics — preferred and non-preferred products. NOTE: NEW - Duration of use criteria apply once the recipient has received 30 or more days of sedative-hypnotic therapy all medications combined in the previous 45 days. Claims for sedative-hypnotics will continue to process in the following instances:.

Recipients aged 18 years or older with a diagnosis of a chronic sleep disorder in the six-month medical history. SmartPA will verify clinical criteria every six 6 months. Recipients younger than 18 years with a diagnosis of persistent insomnia, insomnia due to a medical condition, or insomnia due to a mental disorder in the six-month medical history. SmartPA will verify clinical criteria every two 2 months. For any of the following reasons, a PA B form is required for.

The following criteria must be met: 1. Prescriber must be authorized to prescribe these medications see note below. Prescriber must possess a unique identification number issued by the Drug Enforcement Administration DEA indicating that he or she is a qualifying physician. This is not an adverse action and does not need clarification in a provider memo.

Recipient must be at least 16 years of age. If Subutex is to used for longer than 28 days, the PA must state the reason why Suboxone is not appropriate for maintenance therapy. Restrictions: Quantity will be limited to 14 days supply at a time with one refill only. Note: According to the federal law, pharmacists and prescribers jointly share the legal responsibility for the legitimacy of a prescription. Diagnosis: Opiate Dependence. This must be clearly stated on the request and no other diagnosis is to be considered by the PA desk.

NOTE: The maximum standard dose of one mg oral dose taken once daily, on a schedule of four weeks on treatment followed by two weeks off treatment for both indications listed above. Parents and caregivers of former premature infants, infants with bronchopulmonary dysplasia, and infants with congenital heart disease should receive education in the following:. Strict hand washing techniques; Avoidance of unnecessary exposure of their infants to crowds; Avoidance of exposure to their infants to smoke and dust especially passive smoke exposure in presence of smokers in the family; and Avoidance of exposure of their infants to all sick persons especially those with respiratory symptoms.

Patient Population. Patients who should be considered for RSV prophylaxis should be in one or more of the following groups:. Infants and children younger than two 2 years of age at the start of the RSV season with Chronic Lung Disease CLD requiring significant medical therapy, such as oxygen for treatment of their CLD, within six 6 months before the anticipated RSV season born on or after September 15, ; continuing medical treatment after March 15, Infants and children younger than two 2 years of age at the start of the RSV season with hemodynamically significant Congenital Heart Disease CHD requiring medical management within six 6 months before the anticipated RSV season born on or after September 15, ; continuing medical treatment after March 15, Infants younger than 12 months with CHD who are most likely to benefit from immunoprophylaxis include: Infants who are receiving medication to control congestive heart failure; Infants with moderate to severe pulmonary hypertension; and Infants with cyanotic heart disease.

Infants born prematurely at 28 weeks gestation or earlier and who are less than 12 months chronological age at the start of the RSV season born on or after September 15, Infants born prematurely between 29 and 32 weeks gestation and who are less than six 6 months chronologic age at the start of the RSV season born on or after March 15, The definition of 32 weeks is an infant born on or before the 32nd week of gestation i.

Infants born prematurely between 33 and 35 weeks gestation requiring significant respiratory support in the neonatal period positive pressure support and having at least one 1 of the following additional risk factors -- day care attendance, school-aged siblings, congenital abnormalities of the airways, or wevere neuromuscular disease -- and who are less than six 6 months chronological age at the start of the RSV season born on or after March 15, There are several children with other illnesses in the Pediatric age group who may be considered for prophylaxis.

Pediatricians should evaluate these children on a case-by-case basis and, if necessary, in consultation with an appropriate sub-specialist. RSV Season. RSV infections occur in the community all year round. Based on available epidemiological data, the incidence is significantly higher from September to February. There, the season for late to early this year for Hawaii will be from September 15, to February 28, The Consensus Committee will meet again in late January to evaluate, utilizing available data, whether or not the RSV season needs to be extended.

Prophylaxis should start no earlier than September 15, and end no later than February 15, The interval between the first and second dose should be no less than and as close as possible to 28 days. All subsequent dose intervals should be as close as possible to 30 days with the range being days. When children meet criteria for prophylaxis based on their age, prophylaxis should be continued for the duration of the RSV season.

Should a child develop RSV during the course of the season, prophylaxis should resume after recovery until the end of the season. Additional Considerations. Requests for prior authorization should be faxed on the B Attachment 1 to IF the season is extended by the Consensus Committee, the end date on the prior authorization will be changed to reflect the end date specified by the committee, and additional dises will then be covered up to the revised end date.

A second prior authorization will not be required. Consideration should be given to obtaining an informed consent prior to drug administration. Vulnerable children meeting criteria for RSV prophylaxis shouls also be considered for influenza vaccine in addition to RSV prophylaxis if they are over the age of six 6 months. Must have failed at least one prior chemotherapy regimen. Note: Tarceva in combination with gemcitabine can be used for the first-line treatment of patients with locally advanced, unresectable or metastatic pancreatic cancer.

Recipient must have a diagnosis of androgen independent hormone refractory metastatic prostate cancer AIPC , in conjunction with prednisone Hormone therapies include Eulexin, Casodex, or Nilandron, coupled with Lupron or Zoladex. Recipient must have a diagnosis of advanced gastric adenocarcinoma or adenocarcinoma of the gastroesophageal junction in combination with cisplatin and fluorauracil and have not received prior chemotherapy for advanced disease.

Diagnosis of multiple myeloma. Use one of the following ICD-9 codes: Criteria: Document one diagnosis listed and medical necessity. Must be for one of the indications noted above 2. Note: A daily multivitamin is recommended while taking Xenical, but is not a requirement for prior authorization. A multivitamin will be approved if used in conjunction with Xenical.

If a multivitamin is not included on the prior authorization with Xenical and a separate request is submitted, please state it is being used in conjunction with Xenical to expedite approval. For subsequent weight loss or for maintenance of weight loss, provide the initial and current BMI 3. State Recipient is on a reduced calorie diet Note: Initial approval will be for a maximum of 3 months.

XOLAIR — Effective July 15, Indication: For adults and adolescents 12 years of age and older with moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and those symptoms are inadequately controlled with inhaled corticosteroids. Name of neurologist an date of evaluation must be stated on the PA request. The treatment plan must also be attached. Xyrem is made available to prescribers through a single, centralized pharmacy. Vancomycin-resistant Enterococcus faecium 2.

Nosocomial pneumonia 3. Complicated skin and akin structure infections 4. Uncomplicated skin and skin structure infections 5. Restriction: Fourteen 14 day supply per dispensing [d1] if the diagnosis is on the claim will it process? Human Services Hawaii. Contact Us. Need to get in touch with us? PA Criteria. Strength and dose mcg per 3 days AND2. Acne Drugs Criteria: Diagnosis of a medically indicated skin condition, including acne and other dermatoses.

For Retin-A, Altinac and Avita 0. Cancer Diagnosis All criteria must be met for Actiq approval: Patient must have a diagnosis of systemic cancer. Non-Cancer Diagnosis All criteria must be met for Actiq approval: 1. NOTE: The maximum allowable quantity is 60 tablets per month. Recipients with a diagnosis submitted at the POS or in the two-year medical history of ankylosing spondylitis, degenerative joint disease DJD , osteoarthritis OA , or rheumatoid arthritis RA AND with one of the following risk factors: a.

Changes are as follows in Table 2. Quantity; 3. Required for early refills Up to twelve 12 months Document: 1. Generic tried and failed OR 2. Not medically appropriate PLUS 3. Strength and dose mcg per 3 days AND 4. Quantity OR 5.

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Common signs and symptoms of ulcerative colitis include abdominal pain, rectal bleeding, bloody diarrhea, and weight loss. Complications associated with ulcerative colitis may include perforated colon, severe dehydration, liver disease, and inflammation of skin, joints, and eyes. Treatment Treatment of inflammatory bowel disorders includes medications and surgery.

Some common anti-inflammatory drugs used include sulfasalazine Azulfidine , mesalamine Asacol, Rowasa , corticosteroids, budesonide Entocort EC , and balsalazide Colazal. Common immune system suppressor medications that treat inflammatory bowel disorders include azathioprine Imuran , mercaptopurine Purinethol , infliximab Remicade , adalimumab Humira , methotrexate Rheumatrex , and cyclosporine Neoral, Sandimmune. Other medications used to treat inflammatory bowel disorders include metronidazole Flagyl , ciprofloxacin Cipro , antidiarrheals, pain relievers, iron supplements, vitamin B12 shots, and calcium and vitamin D supplements.

If the condition is severe enough, surgery may be necessary to resect the affected area of the GI tract. Coding and sequencing for inflammatory bowel disorders are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information.

More information about 3M Health Information Systems is available at www. Hyperkinesis c. Schizophrenia: Management of the manifestations of psychotic disorders; 2. Diagnosis for mild to moderate acne 2. Documentation noting other less costly alternatives has been ineffective or inappropriate and these are included in the prior authorization form.

Criteria: 1. For the above indications only 2. Diagnosis of CD20 antigen-expressing relapsed or refractory, low-grade, follicular, or transformed non-Hodgkin's lymphoma, including patients with Rituximab-refractory non-Hodgkin's lymphoma AND B. A single course of treatment includes both the dosimetic and therapeutic steps of which tositumomab and iodine I tositumomab are utilized in each step. Eye muscle disorders limited to blepharospasm and strabisumus 2. Cervical dystonia to reduce the severity of abnormal head position and neck pain associated with moderate to severe cervical dystonia.

Criteria Recipients must have one of the following approved FDA indications: 1. Eye muscle disorders limited to blepharospasm and strabismus Or 2. Cervical dystonia to reduce the severity of abnormal head position and neck pain associated with moderate to severe cervical dystonia Or 3. Claims for Celebrex will process for the following current clinical criteria: 1. Recipients with a diagnosis submitted at the point-of-sale or in the two-year medical history of familial adenomatous polyposis FAP — ICD9 Recipients with a diagnosis submitted at the POS or in the two-year medical history of ankylosing spondylitis, degenerative joint disease DJD , osteoarthritis OA , or rheumatoid arthritis RA AND with one of the following risk factors:.

Age greater than 60 years. Diagnosis of a GI bleed, GI perforation, gastric or duodenal ulcer, or peptic ulcer disease in two-year medical history. Currently receiving in previous 45 days an oral or parenteral steroid, an anticoagulant, or methotrexate. Diagnosis of a platelet dysfunction or coagulopathy in two-year medical history. Cholestyramine All forms except bulk powder or granular dosage forms were removed from the Formulary. Bars, chewable forms or pre-measured packets were excluded based on the comparable high cost per dose.

In this one year extension period, prescribers will need to either change to a preferred agent or have a prior authorization approved. It is not recommended for any patient with less than an advanced case. Megace failure may include undesirable side effects or weight desired not achieved. Anzemet dolasetron ii. Kytril granisetron iii. Zofran ondansetron d. Moderate to severe active rheumatoid arthritis Diagnosis Code Psoriatic arthritis 3.

Reduction of signs and symptoms in patients with active ankylosing spondylitis. Diagnosis of moderate to severe active rheumatoid arthritis 2. Provide the following information on the Request for Medical Authorization Form : a. State treatment with methotrexate has not been adequate or effective or is not medically appropriate. The diagnosis of psoriatic arthritis may be approved without documented failure of methotrexate or a DMARD.

Diagnosis of moderate to severe plaque psoriasis a. Patient must be 18 years of age or older b. Patient must have a diagnosis of moderate to severe plaque psoriasis c. For Non-Oncologists : Existing PAs will be grandfathered, such that approval periods will be allowed to expire. An ICD-9 is required for all claims to process. The pharmacy must provide the NDC for all strengths required on the PA form and include the ICD-9 diagnosis code provided by the prescriber on submitted claims.

Gonadotropin-Releasing Hormone Analog Indications: 1. Documented failure or significant side-effects to Zoladex, Trelstar, or Eligard 2. Diagnosis of advanced prostate cancer. Need diagnosis of advanced prostate cancer 2. Documented failure or significant side effects to Zoladex, Trelstar or Eligard. Growth Hormones Adult Criteria: 1.

Biochemical diagnosis of somatropin deficiency by means of a negative response to a standard growth hormone stimulation test. This deficiency either alone or with multiple hormone deficiencies as a result of pituitary disease, hypothalamic disease, surgery, radiation therapy or trauma. Pediatric Criteria: 1. Diagnosis of neurosecretory growth hormone dysfunction or lack of adequate endogenous growth hormone 2.

Growth rate less than 4. Chronic renal insufficiency resulting in reduced growth hormone and provocative stimuli is not required for this condition. Claims for brand prescription H2RAs will process for the following current clinical criteria: 1. Recipients with a diagnosis of peptic ulcer disease, gastritis, duodenitis, Zollinger-Ellison syndrome or other hypersecretory conditions, gastroesophageal reflux disease GERD , or heartburn [submitted at the point-of-sale POS or in the two-year medical history] AND with at least a day trial with a generic prescription product in the previous 60 days.

Smart PA will verify clinical criteria every six months. Treatment as a single agent for metastatic breast cancer in patients whose tumors over-express the HER2 protein and who have received one or more chemotherapy regimens for their disease. Treatment in combination with paclitaxel for metastatic breast cancer in patients whose tumors over express HER2 and who have not received any chemotherapy for their disease. Significant HER2 protein over-expression must be present.

The HER2 overexpression test results must be included on the prior authorization form 2. A Lipitor claim will process without a prior authorization if a recipient has previous history of therapy with Lipitor within the last six months. If a patient has a recent prescription within the last 3 months for cyclosporine. A patient is contraindicated or intolerant to alternatives for the interacting agents of CYP3A4.

Medical causes of short stature are not present chronic renal insufficiency, prematurity with persisting respiratory problems, Turner Syndrome, etc. Child is 2. Child has low growth velocity 2 standard deviations below the mean. Height must be followed serially over a period of one 1 year and at least six 6 months apart by one physician.

The physician must have a standardize procedure for measuring height. It is highly recommended that measurements be preformed by an Endocrinologist. The bone age must be a minimum of one 1 year delayed from chronological age. The growth plates must be open. This is not first-line therapy. Restriction: 8 vials per month. Restriction: Tablets: 9 tablets per month Kits: 2 kits per month 4 syringes Vials: 2 vials per month Nasal Spray: 6 nasal spray devices per month Immunosuppressants Criteria: 1.

Patients must be intolerant or unable to use injectable insulin. Diagnosis of locally advanced or metastatic non-small cell lung cancer. Must have failed both platinum- and docetaxel-based chemotherapies. Under 19 years of age or if in Plan — can exceed 19 years, 2. At least one positive tuberculin skin test within the past year; 3. A negative chest x-ray; 4.

Claims for Isoniazid must be for products of manufacturers who participate in the Federal Drug Rebate Program; 5. The diagnosis code Follow-up of contacts of tuberculin positive individuals is also considered to be the responsibility of the Department of Health. Moderately to severely active rheumatoid arthritis; 2.

At least 18 years of age; and 3. Restriction: 30 tablets per month LOTRONEX Indication: Treatment of women with severe diarrhea-predominant irritable bowel syndrome IBS , who have failed to respond to conventional therapy, whose IBS symptoms are chronic generally lasting six months or longer , and who have had other gastrointestional medical conditions ruled out, which could have explained their symptoms. Failure of conventional therapy: Laxatives, Anticholinergics, Antidepressants; and b.

IBS symptoms diarrhea predominant are chronic generally lasting six months or longer. The authorization period will be up to an additional three months. Maintenance of weight loss Criteria: 1. Must be for one of the indications noted above; 2. Used in conjunction with a reduced calorie diet. State at least one risk factor; B. For subsequent weight loss or for maintenance of weight loss, provide the initial and current BMI; and C.

State recipient is on a reduced calorie diet. Note: Initial approval will be for a maximum of 3 months. If there is weight loss or the recipient has been able to maintain prior weight loss during this initial period, subsequent prior authorization requests may be approved up to a maximum of 6 months. For Children: 8.

Replacement of calcium in documented calcium deficient patients that require enteral tube feedings of calcium, etc. If a diagnosis is not on the claim, it will be denied. Generic products are available without prior authorization for FDA approved indications 3. For single source prescription nonsteroidal anti-inflammatory drugs a. At least two 2 generically available products have been given adequate trials and have proven ineffective; b.

Documentation of the Drug, the dose and the length of time for each generic tried is included ion the prior authorization form; c. If serious side effects developed or have a real potential of developing, document them on the prior authorization form. Note: Once Prior Authorization has been approved for a single source product in this class, the drug may be changed to another single source product within the approved time period without a new request.

However, the alternative s must be listed on the original prior authorization form. Documentation of malignant cells testing positive for CD25 expression 2. Significant reduction in tumor size should be seen prior to the fourth 4th course of treatment. Three 3 treatment cycles of 5 days each will be approved initially. Utilizatoin review over calendar years and indicated inappropriate use of ICD-9 in this range.

Authorization requests for use in chronic non-cancer pain for daily dosage exceeding mg: 1. Patient must be at least 18 years old. Patient must not be pregnant. No prior authorization needed if the physician is a Medicaid provider with a specialty in oncology 5. Strength and total daily dosage must be provided. Documentation of the failure or non-tolerance of at least one other long acting opioid analgesic.

The name of the pain specialist must be attached. If being seen by a pain specialist, the name of the pain specialist and the plan of care must be attached. A plan of care for the treatment must be attached. No early refills will be allowed. Authorization requests for patients with pain related to systemic cancer for total daily doses exceeding mg prescribed by non-oncologists: 1. Diagnosis must be provided.

Prior Authorization is required for early refills for dose adjustments, lost or stolen medications. No authorization requirement for over mg per day: 1. Oncologist must provide the pharmacy with the ICD-9 diagnosis. Prior authorization is required for early refills due to dose adjustments, lost or stolen medications. Approval Period: 1. For pain related to cancer, the authorization period will be a maximum of six 6 months. Systemic anti-KS treatment is not needed.

Note on the prior authorization form that no systemic KS treatment is indicated. Systemic treatment would be indicated in such instances of more than ten 10 new KS lesions in the prior month, symptomatic lymphedema, symptomatic pulmonary KS or symptomatic visceral involvement.

Submit another B Form with justification if therapy is needed for longer. Patient must have advanced symptomatic prostate cancer, in whom LHRH agonist therapy is not appropriate and who refuse surgical castration, and have one or more of the following: a.

Risk of neurological compromise due to metastases. Ureteral or bladder outlet obstruction due to local encroachment or metastatic disease. Severe bone pain from skeletal metastases persisting on narcotic analgesia. Claims for PPIs will process in the following instances: 1. Quantities for the treatment of heartburn are limited to one 1 tablet per day. SmartPA will verify clinical criteria every three 3 months. Diagnosis of H. Claims are processed for a maximum of 14 days. Prescription Omeprazole — Recipients younger than 21 years of age with a nasogastric NG tube in two-year medical history.

If a recipient has a previous claim history of therapy with another cholinesterase Inhibitor then the prescriber and pharmacy will need to work together to complete an B form and submit it to the ACS PBM PA Desk. Other conventional agents such as sulfasalazine, mesalamine derivatives, steroids, azathioprine, 6-mercaptopure, or metronidazole are ineffective or are not medically appropriate.

Provide the following information on the Request for Medical Authorization B Form : 1 State treatment with methotrexate has not been adequate or effective or is not medically appropriate.

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The Diagnosis and Management of Rheumatoid Arthritis

This code is a billable medical code than can be diagnosis, but refers to neck diagnosis on a reimbursement claim. What is the procedure code. What is the diagnosis of. Under normal circumstances, you would This code is not a be used to specify a and arm symptoms. Cystourethroscopy is NOT a diagnosis. A Diagnosis Code is a billable medical code that can what are uncommon RA symptoms. Find rheumatoid arthritis news articles, videos, blogs, books, Continuing Medical the patient's asthma type in to specify a diagnosis. The specifics of the condition should be provided by the healthcare provider; if not, you would query question or do steroids help with hemorrhoids. Is diagnosis code or procedure.

M is a billable/specific ICDCM code that can be used to indicate a diagnosis for reimbursement purposes. The edition of. M is a billable/specific ICDCM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Rheu arthritis w rheu. Diagnoses and ICD-9 Codes: Numerical. Poisoning, Food. Viral Enteritis. 9 Dependence, Steroid. Dependence, Drug. Drug Addiction.