anxiolytics and sedatives/hypnotics (ashs)...anxiolytics – alprazolam drugs requiring prior...

May 14, 2015 Copyright © 2011-2015 Health Information Designs, LLC 1

Texas Prior Authorization Program

Clinical Edit Criteria

Drug/Drug Class

Anxiolytics and Sedatives/Hypnotics (ASHs) Anxiolytics – Alprazolam

Anxiolytics – Buspirone

Anxiolytics – Chlordiazepoxide, Meprobamate & Oxazepam

Anxiolytics – Clonazepam & Diazepam

Anxiolytics – Clorazepate

Anxiolytics – Lorazepam

Sedatives/Hypnotics – Adults

Sedatives/Hypnotics – Chloral Hydrate & Butabarbital

Sedatives/Hypnotics – Flurazepam

Sedatives/Hypnotics – Ramelteon

Note: Click the hyperlink to navigate directly to that section.

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

Texas Prior Authorization Program Clinical Edits ASHs


Revision Notes

Updated alprazolam clinical edit criteria logic, logic diagram and supporting tables.

Texas Prior Authorization Program Clinical Edits Anxiolytics – Alprazolam


Anxiolytics and Sedatives/Hypnotics (ASHs)

Anxiolytics – Alprazolam Drugs Requiring Prior Authorization

Drugs Requiring Prior Authorization

Label Name GCN

ALPRAZOLAM 0.25MG TABLET 14260


ALPRAZOLAM 1MG TABLET 14262

ALPRAZOLAM 1MG/ML ORAL CONC 14264


ALPRAZOLAM ER 0.5MG TABLET 17423

ALPRAZOLAM ER 1MG TABLET 17424



ALPRAZOLAM ODT 0.25MG TABLET 24368


ALPRAZOLAM ODT 1MG TABLET 24373


NIRAVAM 0.5MG ODT TABLET 24369

NIRAVAM 1MG ODT TABLET 24373


XANAX 0.25MG TABLET 14260


XANAX 1MG TABLET 14262


XANAX XR 0.5MG TABLET 17423

XANAX XR 1MG TABLET 17424



Texas Prior Authorization Program Clinical Edits ASHs



Anxiolytics – Alprazolam Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a diagnosis of drug abuse in the last 730 days?

[ ] Yes (Deny) [ ] No (Go to #2)

2. Is the client less than (<) 18 years of age?


3. Does the client have a history of an alprazolam agent for greater than (>) 120

days in the last 365 days?

[ ] Yes (Go to #4) [ ] No (Approve – 120 days)

4. Is the incoming request for less than or equal to (≤) 1 days supply?

[ ] Yes (Go to #5) [ ] No (Go to #6)

5. Is the incoming request for less than or equal to (≤) 5 units per day?

[ ] Yes (Approve – 1 day) [ ] No (Deny)

6. Has the client had 1 claim for a selective serotonin reuptake inhibitor (SSRI) or a serotonin norepinephrine reuptake inhibitor (SNRI) in the last 180 days? [ ] Yes (Go to #7) [ ] No (Deny)

7. Does the client have a diagnosis of generalized anxiety disorder (GAD) or

panic disorder in the last 730 days?

[ ] Yes (Approve – 120 days) [ ] No (Deny)

Texas Prior Authorization Program Clinical Edits Anxiolytics – Buspirone


Anxiolytics and Sedatives/Hypnotics

(ASHs) Anxiolytics – Alprazolam

Clinical Edit Criteria Logic Diagram

Step 3

Does the client have a history of an

alprazolam agent for > 120 days in the last

365 days?

Deny Request

Approve Request(120 days)

Yes

No

Yes

Step 4

Is the incoming request for ≤ 1 days

supply?

No

No

Step 5

Is the incoming request for ≤ 5 units

per day?

Yes

Step 1

Does the client have a diagnosis of drug

abuse in the last 730 days?

Deny Request Yes

No

No

Yes

Deny Request

Deny Request

Yes

No

Yes

No

Approve Request(1 day)

Step 2

Is the client < 18 years of age?

Step 6

Has the client had 1 claim for an SSRI or an SNRI in the last

180 days?

Step 7

Does the client have a diagnosis of GAD or panic disorder in the last 730 days?

Approve Request(120 days)

Deny Request




(ASHs)

Anxiolytics – Buspirone Drugs Requiring Prior Authorization


Label Name GCN

BUSPAR 5 MG TABLET 28890



BUSPIRONE HCL 5 MG TABLET 28890

BUSPIRONE HCL 7.5 MG TABLET 13037







(ASHs)

Anxiolytics – Buspirone Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a history of a buspirone agent for 90 days in the last 150

days?

[ ] Yes (Approve – 365 days) [ ] No (Go to #2)


[ ] Yes (Go to #3) [ ] No (Go to #4)


[ ] Yes (Approve – 1 day) [ ] No (Go to #4)



5. Is the client between 6 and 18 ( 6 and 18) years of age?

[ ] Yes (Go to #6) [ ] No (Go to #9)

6. Does the client have a diagnosis of anxiety disorder in the last 730 days?

[ ] Yes (Go to #7) [ ] No (Go to #8)

7. Does the client have a history of an anxiolytic agent for 60 days in the last 90

days?

[ ] Yes (Deny) [ ] No (Approve – 60 days)


days?



[ ] Yes (Go to #10) [ ] No (Go to #11)



10. Does the client have a history of an anxiolytic agent for 180 days in the last

200 days?



days?





(ASHs)

Anxiolytics – Buspirone


Step 1

Does the client have a

history of a buspirone

agent for 90 days in the

last 150 days?

Step 2

Is the incoming request

for ≤ 1 days supply?

Step 3


for ≤ 5 units per day?No

Yes

Approve Request

(365 days)

No No

Approve Request

(1 day)

Yes Yes

Step 4

Is the client < 6 years of

age?

Step 5

Is the client between 6

and 18 years of age?

Step 6


diagnosis of anxiety

disorder in the last 730

days?

Step 7


history of an anxiolytic


last 90 days?

Step 8




last 60 days?

Yes

Step 9




days?

Step 10



agent for 180 days in

the last 200 days?

Step 11




last 90 days?

Approve Request

(60 days)

Yes

No

Yes

Deny

Deny

Yes

No

Approve Request

(30 days)

No

Yes

Approve Request

(180 days)

Yes

No

No

DenyYes

No

No

Yes

No

No

Approve Request

(60 days)

Texas Prior Authorization Program Clinical Edits Anxiolytics – Chlordiazepoxide, Meprobamate & Oxazepam



(ASHs) Anxiolytics – Chlordiazepoxide, Meprobamate &

Oxazepam



Label Name GCN

CHLORDIAZEPOXIDE 5 MG CAPSULE 14033



MEPROBAMATE 200 MG TABLET 13801


OXAZEPAM 10 MG CAPSULE 14230







Oxazepam

Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a history of a chlordiazepoxide (CLD), meprobamate

(MePB), or oxazepam (OXAZ) agent for 90 days in the last 150 days?



[ ] Yes (Go to #3) [ ] No (Go to #4)




[ ] Yes (Go to #6) [ ] No (Go to #5)

5. Does the client have a diagnosis of drug abuse in the last 730 days?

[ ] Yes (Deny)

[ ] No (Go to #6)




[ ] Yes (Go to #8) [ ] No (Go to #11)


[ ] Yes (Go to #9) [ ] No (Go to #10)


days?





60 days?



[ ] Yes (Go to #12) [ ] No (Go to #13)


200 days?



90 days?






Oxazepam


Step 1


history of a CLD, MePB,

or OXAZ agent for 90

days in the last 150

days?

Step 2



Step 3


for ≤ 5 units per day?

No

Yes

Approve Request

(365 days)

Yes

Approve Request

(60 days)

No

Yes

Step 4




days?

Step 5


diagnosis of drug abuse

in the last 730 days?

Step 6


age?

Step 7



Step 8




days?

Step 9




last 90 days?

Step 10




last 60 days?

No

No

Deny

Yes

Step 11




days?

Step 12




the last 200 days?

Step 13




last 90 days?

Yes

No No

Deny

No

No

Approve Request

(30 days)

No

Yes

Approve Request

(60 days)

Approve Request

(180 days)

No

No

Yes

Yes

NoYes

Approve Request

(1 day)

Yes

No

Deny

Yes

Yes

YesDeny

YesNo

Texas Prior Authorization Program Clinical Edits Anxiolytics – Clonazepam & Diazepam



(ASHs)

Anxiolytics – Clonazepam & Diazepam Drugs Requiring Prior Authorization


Label Name GCN

CLONAZEPAM 0.125 MG DIS TAB 19467

CLONAZEPAM 0.5 MG DIS TABLET 19469

CLONAZEPAM 1 MG DIS TABLET 19470

CLONAZEPAM 0.25 MG ODT 19468

CLONAZEPAM 2 MG ODT 19472

CLONAZEPAM 0.5 MG TABLET 17470

CLONAZEPAM 1 MG TABLET 17471


DIASTAT 2.5 MG PEDI SYSTEM 48131

DIASTAT ACUDIAL 5-7.5-10 MG KT 25598

DIASTAT ACUDIAL 12.5-15-20 MG 25599

DIAZEPAM 5-7.5-10 MG GEL KIT 25598

DIAZEPAM 5 MG/ML ORAL CONC 45500

DIAZEPAM 2.5 MG RECTAL GEL 48131

DIAZEPAM 20 MG RECTAL GEL 25599

DIAZEPAM 5 MG/5 ML SOLUTION 45560

DIAZEPAM 2 MG TABLET 14221



KLONOPIN 0.5 MG TABLET 17470

KLONOPIN 1 MG TABLET 17471





Anxiolytics – Clonazepam & Diazepam Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a history of a clonazepam or diazepam agent for 90

days in the last 150 days?



[ ] Yes (Go to #3) [ ] No (Go to #4)



4. Does the client have a diagnosis of epilepsy in the last 730 days?


5. Does the client have a history of an anticonvulsant agent in the last 45 days?


6. Does the client have a diagnosis of muscle disorder in the last 730 days?



[ ] Yes (Go to #9) [ ] No (Go to #8)



9. Is the client less than (<) 6 months of age?

[ ] Yes (Deny) [ ] No (Go to #10)

10. Is the client between 6 months and 18 years ( 6 months and 18 years) of

age?

[ ] Yes (Go to #11) [ ] No (Go to #14)




[ ] Yes (Go to #12) [ ] No (Go to #13)


90 days?



60 days?



[ ] Yes (Go to #15) [ ] No (Go to #16)


200 days?



90 days?





(ASHs)

Anxiolytics – Clonazepam & Diazepam Clinical Edit Criteria Logic Diagram

Step 1


history of a clonazepam

or diazepam agent for

90 days in the last 150

days?

Step 2



Step 3



No

Yes

Step 4


diagnosis of epilepsy in

the last 730 days?

Step 5


history of an

anticonvulsant agent in

the last 45 days?

Step 6


diagnosis of muscle


days?

Approve Request

(365 days)

Yes

Approve Request

(1 day)

Approve Request

(365 days)

No Yes

No

Approve Request

(365 days)

Yes

Step 7




days?

Step 8




Step 9

Is the client < 6 months

of age?

Step 10


months and 18 years of

age?

Step 11




days?

Step 12




last 90 days?

Step 13




last 60 days?

No

Approve Request

(365 days)

YesNoNoDeny

Yes

No

DenyNo Yes

Step 14




days?

Step 15




the last 200 days?

Step 16




last 90 days?

No

Approve Request

(60 days)

Yes

No No

Yes

Deny

Deny

Yes

Yes

No

Approve Request

(30 days)

No

YesDeny

Yes

No

Approve Request

(60 days)

Yes

Approve Request

(180 days)

No

Yes

Yes

No

Texas Prior Authorization Program Clinical Edits Anxiolytics – Clorazepate



(ASHs)

Anxiolytics – Clorazepate Drugs Requiring Prior Authorization


Label Name GCN

CLORAZEPATE 3.75 MG TABLET 14092


CLORAZEPATE 15 MG TABLET 14090

TRANXENE SD 11.25 MG TABLET 14100

TRANXENE SD 22.5 MG TAB 14091

TRANXENE T-TAB 3.75 MG 14092


TRANXENE T-TAB 15 MG 14090




(ASHs)

Anxiolytics – Clorazepate Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a history of a clorazepate agent for 90 days in the last

150 days?



[ ] Yes (Go to #3) [ ] No (Go to #4)








[ ] Yes (Go to #8) [ ] No (Go to #7)






[ ] Yes (Go to #10) [ ] No (Go to #13)


[ ] Yes (Go to #11) [ ] No (Go to #12)




90 days?



60 days?



[ ] Yes (Go to #14) [ ] No (Go to #15)


200 days?

[ ] Yes (Deny) [ ] No (Approve 180 days)


90 days?





(ASHs)

Anxiolytics – Clorazepate Clinical Edit Criteria Logic Diagram

No

Step 1


history of a clorazepate


last 150 days?

Step 2



Step 3



No

Yes

Step 4



the last 730 days?

Step 5


history of an


the last 45 days?

Approve Request

(365 days)

Yes No

Approve Request

(365 days)

No Yes

Approve Request

(365 days)

Yes

Step 6




days?

Step 7




Step 8


age?

Step 9



Step 10




days?

Step 11




last 90 days?

Step 12




last 60 days?

NoDeny

Yes

No

DenyNo Yes

Step 13




days?

Step 14




the last 200 days?

Step 15




last 90 days?

No

Approve Request

(60 days)

Yes

NoNo

Yes

Deny

Deny

Yes

Yes

No

Approve Request

(30 days)

No

Yes

Approve Request

(60 days)

Approve Request

(180 days)

No

Yes

Yes

No

Yes

Yes

No

No

Approve Request

(1 day)

Texas Prior Authorization Program Clinical Edits Anxiolytics – Lorazepam



(ASHs)

Anxiolytics – Lorazepam Drugs Requiring Prior Authorization


Label Name GCN

ATIVAN 0.5 MG TABLET 14160

ATIVAN 1 MG TABLET 14161


ATIVAN 2 MG/ML VIAL 14140


LORAZEPAM 2 MG/ML ORAL CONCENT 19601

LORAZEPAM 0.5 MG TABLET 14160

LORAZEPAM 1 MG TABLET 14161


LORAZEPAM 2 MG/ML VIAL 14140


LORAZEPAM INTENSOL 2 MG/ML 19601




(ASHs)

Anxiolytics – Lorazepam Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a history of a lorazepam agent for 90 days in the last 150

days?



[ ] Yes (Go to #3) [ ] No (Go to #4)







6. Does the client have a diagnosis of muscle disorder in the last 730 days?



[ ] Yes (Go to #9) [ ] No (Go to #8)




[ ] Yes (Deny) [ ] No (Go to #10)


[ ] Yes (Go to #11) [ ] No (Go to #14)




[ ] Yes (Go to #12) [ ] No (Go to #13)


90 days?



60 days?



[ ] Yes (Go to #15) [ ] No (Go to #16)


200 days?

[ ] Yes (Deny) [ ] No (Approve 180 days)


90 days?





(ASHs)

Anxiolytics – Lorazepam Clinical Edit Criteria Logic Diagram

Step 1

Does the client have

history of a lorazepam


last 150 days?

Step 2



Step 3



No

Yes

Step 4



the last 730 days?

Step 5


history of an


the last 45 days?

Step 6


diagnosis of muscle


days?

Approve Request

(365 days)

Yes No

Approve Request

(1 day)

Approve Request

(365 days)

No Yes

No

Approve Request

(365 days)

Yes

Step 7




days?

Step 8




Step 9

Is the client < 12 years

of age?

Step 10



Step 11




days?

Step 12




last 90 days?

Step 13




last 60 days?

No

Approve Request

(365 days)

YesNoNoDeny

Yes

No

DenyNo Yes

Step 14




days?

Step 15




the last 200 days?

Step 16




last 90 days?

No

Approve Request

(60 days)

Yes

No No

Yes

Deny

Deny

Yes

Yes

No

Approve Request

(30 days)

No

YesDeny

Yes

No

Approve Request

(60 days)

Yes

Approve Request

(180 days)

No

Yes

Yes

No

Texas Prior Authorization Program Clinical Edits Sedatives/Hypnotics – Adults



(ASHs)

Sedatives/Hypnotics – Adults Drugs Requiring Prior Authorization


Label Name GCN

AMBIEN 5 MG TABLET 00870


AMBIEN CR 6.25 MG TABLET 25456


DORAL 15 MG TABLET 40870

EDLUAR 5 MG SL TABLET 26183


ESTAZOLAM 1 MG TABLET 19181


HALCION 0.25 MG TABLET 14280

LUNESTA 1 MG TABLET 23927



RESTORIL 7.5 MG CAPSULE 13845

RESTORIL 15 MG CAPSULE 13840



SONATA 5 MG CAPSULE 92713


TEMAZEPAM 7.5 MG CAPSULE 13845

TEMAZEPAM 15 MG CAPSULE 13840



TRIAZOLAM 0.125 MG TABLET 14282


ZALEPLON 5 MG CAPSULE 92713


ZOLPIDEM TART ER 6.25 MG TAB 25456


ZOLPIDEM TARTRATE 5 MG TABLET 00870





(ASHs)

Sedatives/Hypnotics – Adults Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a history of a sedative/hypnotic agent for 90 days in the

last 150 days?



[ ] Yes (Go to #3) [ ] No (Go to #4)



4. Does the client have a diagnosis of chronic sleep disorder in the last 730

days?

[ ] Yes (Go to #6) [ ] No (Go to #5)





7. Does the client have a diagnosis of insomnia in the last 365 days?

[ ] Yes (Go to #8) [ ] No (Go to #9)

8. Does the client have a history of a sedative/hypnotic agent for 90 days in the

last 120 days?



last 60 days?





(ASHs)

Sedatives/Hypnotics – Adults Clinical Edit Criteria Logic Diagram

Yes

Step 7


diagnosis of insomnia in

the last 365 days?

Step 8


history of a sedative/

hypnotic agent for 90


days?

Approve Request

(90 days)

YesNo

Yes

Step 9




days in the last 60

days?

No

No

Deny Deny

Approve Request

(30 days)

Step 1





days?

Step 2



Step 3



No

Yes

Approve Request

(365 days)

Yes Yes

Approve Request

(1 day)

No

Step 4


diagnosis of a chronic

sleep disorder in the

last 730 days?

Step 5




Step 6


of age? Deny

No

No

Yes

No

No

Yes

DenyYes

Texas Prior Authorization Program Clinical Edits Sedatives/Hypnotics – Chloral Hydrate & Butabarbital



(ASHs) Sedatives/Hypnotics – Chloral Hydrate & Butabarbital



Label Name GCN

BUTISOL SODIUM 30 MG/5 ML ELX 13084

BUTISOL SODIUM 30 MG TABLET 13102


CHLORAL HYDRATE 500 MG/5 ML 13471

SOMNOTE 500 MG SOFTGEL 13433





Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a history of a chloral hydrate or butabarbital agent for

90 days in the last 150 days?



[ ] Yes (Go to #3) [ ] No (Go to #4)




days?

[ ] Yes (Go to #6) [ ] No (Go to #5)



6. Is the client less than (<) 6 months of age? [ ] Yes (Deny) [ ] No (Go to #7)

7. Is the client between 6 months and 18 years ( 6 months and 18 years) of age?

[ ] Yes (Go to #8) [ ] No (Go to #11)

8. Does the client have a diagnosis of insomnia in the last 180 days? [ ] Yes (Go to #9) [ ] No (Go to #10)

9. Does the client have a history of a sedative/hypnotic agent for 30 days in the last 60 days?






11. Does the client have a diagnosis of insomnia in the last 365 days? [ ] Yes (Go to #12) [ ] No (Go to #13)










YesNo

Step 7


months and 18 years of

age?

Step 8



the last 180 days?

Step 9




days in the last 60

days?

Approve Request

(30 days)

Yes

Step 10




days in the last 30

days?

No

Approve Request

(15 days)

Yes

Step 12





days?

Step 11



the last 365 days?

No

Step 13




days in the last 60

days?

No

Yes

Yes

Deny

Deny

Yes

Yes

Approve Request

(30 days)

Approve Request

(90 days)

No

No

No

Step 1


history of chloral

hydrate or butabarbital


last 150 days?

Step 2



Step 3



No

Yes

Approve Request

(365 days)

Yes Yes

Approve Request

(1 day)

No

Step 4


diagnosis of chronic


last 730 days?

Step 5




Step 6

Is the client < 6 months

of age? Deny

No

No

Yes

No

No

Yes

DenyYes

Texas Prior Authorization Program Clinical Edits Sedatives/Hypnotics – Flurazepam



(ASHs)

Sedatives/Hypnotics – Flurazepam Drugs Requiring Prior Authorization


Label Name GCN

FLURAZEPAM 15 MG CAPSULE 14250





(ASHs)

Sedatives/Hypnotics – Flurazepam Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a history of a flurazepam agent for 90 days in the last

150 days?



[ ] Yes (Go to #3) [ ] No (Go to #4)




days?

[ ] Yes (Go to #6) [ ] No (Go to #5)






[ ] Yes (Go to #8) [ ] No (Go to #11)


[ ] Yes (Go to #9) [ ] No (Go to #10)

9. Does the client have a history of a sedative/hypnotic agent for 30 days in

the last 60 days?





the last 30 days?



[ ] Yes (Go to #12) [ ] No (Go to #13)


the last 120 days?



the last 60 days?





(ASHs)

Sedatives/Hypnotics – Flurazepam Clinical Edit Criteria Logic Diagram

Step 7



Step 8



the last 180 days?

Step 9




days in the last 60

days?

Approve Request

(30 days)

YesYesNo

Step 12





days?

Step 11



the last 365 days?

No

Step 13




days in the last 60

days?

No

Yes

Deny

Yes

Yes

Approve Request

(30 days)

Approve Request

(90 days)

No

Step 10




days in the last 30

days?

No

Approve Request

(15 days)

Yes

Yes

Deny

No

No

Step 1


history of a flurazepam


last 150 days?

Step 2



Step 3



No

Yes

Approve Request

(365 days)

Yes Yes

Approve Request

(1 day)

No

Step 4




days?

Step 5




Step 6


of age? Deny

No

No

Yes

No

No

Yes

DenyYes

Texas Prior Authorization Program Clinical Edits Sedatives/Hypnotics – Ramelteon



(ASHs)

Sedatives/Hypnotics – Ramelteon Drugs Requiring Prior Authorization


Label Name GCN

ROZEREM 8 MG TABLET 25202




(ASHs)

Sedatives/Hypnotics – Ramelteon Clinical Edit Criteria Logic

Note: Click the hyperlink to view the supporting table. 1. Does the client have a history of a ramelteon agent for 90 days in the last 150

days?



[ ] Yes (Go to #3) [ ] No (Go to #4)




[ ] Yes (Deny)

[ ] No (Go to #5)


days?

[ ] Yes (Go to #8) [ ] No (Go to #6)


[ ] Yes (Go to #7) [ ] No (Go to #8)


last 60 days?

[ ] Yes (Deny) [ ] No (Approve - 30 days)


days?

[ ] Yes (Go to #9) [ ] No (Go to #7)




the last 120 days?





(ASHs)

Sedatives/Hypnotics – Ramelteon Clinical Edit Criteria Logic Diagram

Step 1


history of a ramelteon


last 150 days?

Step 3



No

Yes

Approve Request

(365 days)

No

Step 4


of age? DenyYes

Yes

Step 6


history of drug abuse in

the last 730 days?

Step 8




last 365 days?

Step 7




days in the last 60

days?

Approve Request

(30 days)

DenyDeny

Approve Request

(90 days)

Yes

NoNo

Yes

Yes

YesApprove Request

(1 day)

No

Yes

No

Yes

No

Step 2



No No

Step 5




last 730 days?

Step 9





days?

Texas Prior Authorization Program Clinical Edits ASHs – Supporting Tables



(ASHs)

Clinical Edit Criteria Supporting Tables

Alprazolam Agents

History of prior therapy in the last 90 days

Required quantity: 1

Look back timeframe: 150 days

Label Name GCN




ALPRAZOLAM 1MG/ML ORAL CONC 14264


ALPRAZOLAM ER 0.5MG TABLET 17423








NIRAVAM 0.5MG ODT TABLET 24369







XANAX XR 0.5MG TABLET 17423






Anticonvulsant Agents

History of prior therapy



Label Name GCN

BANZEL 40 MG/ML SUSPENSION 29462

BANZEL 200 MG TABLET 98836

BANZEL 400 MG TABLET 98837

CARBAMAZEPINE 100 MG/5 ML SUSP 47500

CARBAMAZEPINE 100 MG TAB CHEW 17460

CARBAMAZEPINE 200 MG TABLET 17450

CARBAMAZEPINE XR 200 MG TABLET 27821

CARBAMAZEPINE XR 400 MG TABLET 27822

CARBATROL ER 100 MG CAPSULE 23934



DEPAKENE 250 MG CAPSULE 17270

DEPAKENE 250 MG/5 ML SOLUTION 17280

DEPAKOTE 125 MG SPRINKLE CAP 17400

DEPAKOTE DR 125 MG TABLET 17292



DEPAKOTE ER 250 MG TABLET 18754

DEPAKOTE ER 500 MG TABLET 18040

DILANTIN 30 MG CAPSULE 17701

DILANTIN 100 MG CAPSULE 17700

DILANTIN 50 MG INFATAB 17250

DILANTIN 125 MG/5 ML SUSP 17241

DIVALPROEX SOD DR 125 MG TAB 17292



DIVALPROEX SOD ER 250 MG TAB 18754

DIVALPROEX SOD ER 500 MG TAB 18040

DIVALPROEX SODIUM 125 MG CAP 17400

EPITOL 200 MG TABLET 17450

EQUETRO 100 MG CAPSULE 13781



ETHOSUXIMIDE 250 MG CAPSULE 17420







Label Name GCN

ETHOSUXIMIDE 250 MG/5 ML SYRP 17430

FELBATOL 600 MG/5 ML SUSP 38020

FELBATOL 400 MG TABLET 38021

FELBATOL 600 MG TABLET 38022

GABAPENTIN 100 MG CAPSULE 780



GABAPENTIN 250 MG/5 ML SOLN 13235

GABAPENTIN 600 MG TABLET 94624

GABAPENTIN 800 MG TABLET 94447

GABITRIL 2 MG TABLET 54681




KEPPRA 100 MG/ML ORAL SOLN 20353

KEPPRA 250 MG TABLET 41587



KEPPRA 1,000 MG TABLET 86223

KEPPRA XR 500 MG TABLET 14305

KEPPRA XR 750 MG TABLET 20765

LAMICTAL 5 MG DISPER TABLET 64323

LAMICTAL 25 MG DISPER TABLET 64322

LAMICTAL 25 MG TABLET 64317




LAMICTAL ODT 25 MG TABLET 23201




LAMICTAL ODT START KIT (BLUE) 23294

LAMICTAL ODT START KIT (GREEN) 23309

LAMICTAL ODT START KT (ORANGE) 23293







Label Name GCN

LAMICTAL TAB START KIT (BLUE) 23969

LAMICTAL TAB START KIT (GREEN) 23972

LAMICTAL TB START KIT (ORANGE) 23973

LAMICTAL XR 25 MG TABLET 24693





LAMICTAL XR START KIT (BLUE) 24851

LAMICTAL XR START KIT (GREEN) 24856

LAMICTAL XR START KIT (ORANGE) 24869

LAMOTRIGINE 5 MG DISPER TABLET 64323

LAMOTRIGINE 25 MG DISPER TAB 64322

LAMOTRIGINE 25 MG TABLET 64317




LEVETIRACETAM 100 MG/ML SOLN 20353

LEVETIRACETAM 250 MG TABLET 41587



LEVETIRACETAM 1,000 MG TABLET 86223

LYRICA 25 MG CAPSULE 23039








MYSOLINE 50 MG TABLET 17322

MYSOLINE 250 MG TABLET 17321

NEURONTIN 100 MG CAPSULE 780








Label Name GCN


NEURONTIN 250 MG/5 ML SOLN 13235

NEURONTIN 600 MG TABLET 94624

NEURONTIN 800 MG TABLET 94447

OXCARBAZEPINE 300 MG/5 ML SUSP 21723

OXCARBAZEPINE 150 MG TABLET 21724



PEGANONE 250 MG TABLET 17260

PHENOBARBITAL 20 MG/5 ML ELIX 12956

PHENOBARBITAL 15 MG TABLET 12971

PHENOBARBITAL 16.2 MG TABLET 97706







PHENOBARBITAL 65 MG/ML VIAL 12894

PHENOBARBITAL 130 MG/ML VIAL 12892

PHENYTEK 200 MG CAPSULE 15038

PHENYTEK 300 MG CAPSULE 15037

PHENYTOIN 125 MG/5 ML SUSP 17241

PHENYTOIN 50 MG/ML VIAL 17200

PHENYTOIN 100 MG/2 ML VIAL 17200

PHENYTOIN 250 MG/5 ML VIAL 17200

PHENYTOIN SOD EXT 100 MG CAP 17700



PRIMIDONE 50 MG TABLET 17322

PRIMIDONE 250 MG TABLET 17321

SABRIL 500 MG POWDER PACKET 64314

SABRIL 500 MG TABLET 64315

STAVZOR DR 125 MG CAPSULE 99981







Label Name GCN



TEGRETOL 100 MG/5 ML SUSP 47500

TEGRETOL 100 MG TABLET CHEW 17460

TEGRETOL 200 MG TABLET 17450

TEGRETOL XR 100 MG TABLET 27820



TOPAMAX 15 MG SPRINKLE CAP 36556

TOPAMAX 25 MG SPRINKLE CAP 36557

TOPAMAX 25 MG TABLET 36553




TOPIRAGEN 25 MG TABLET 36553




TOPIRAMATE 15 MG SPRINKLE CAP 36556

TOPIRAMATE 25 MG SPRINKLE CAP 36557

TOPIRAMATE 25 MG TABLET 36553




TRILEPTAL 300 MG/5 ML SUSP 21723

TRILEPTAL 150 MG TABLET 21724



VALPROIC ACID 250 MG CAPSULE 17270

VALPROIC ACID 250 MG/5 ML SOLN 17280

VIMPAT 10 MG/ML SOLUTION 28643

VIMPAT 50 MG TABLET 14338









Label Name GCN


ZARONTIN 250 MG CAPSULE 17420

ZARONTIN 250 MG/5 ML SYRUP 17430

ZONEGRAN 25 MG CAPSULE 20831

ZONEGRAN 100 MG CAPSULE 92219

ZONISAMIDE 25 MG CAPSULE 20831



Anxiety Disorder Diagnoses

Required diagnosis: 1


ICD-9 Code Description

3080 STRESS REACT, EMOTIONAL

3081 STRESS REACTION, FUGUE

3082 STRESS REACT, PSYCHOMOT

3083 ACUTE STRESS REACT NEC

3084 STRESS REACT, MIXED DIS

3089 ACUTE STRESS REACT NOS

3090 ADJUSTMENT DISORDER WITH DEPRESSED MOOD

3091 PROLONG DEPRESSIVE REACT

3130 OVERANXIOUS DISORDER

29384 ANXIETY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE

30000 ANXIETY STATE NOS

30001 PANIC DISORDER WITHOUT AGORAPHOBIA

30002 GENERALIZED ANXIETY DIS

30009 ANXIETY STATE NEC

30020 PHOBIA NOS

30021 AGORAPHOBIA WITH PANIC DISORDER

30022 AGORAPHOBIA W/O PANIC

30023 SOCIAL PHOBIA

30029 OTHER ISOLATED OR SPECIFIC PHOBIAS

30921 SEPARATION ANXIETY






30922 EMANCIPATION DISORDER

30923 ACADEMIC/WORK INHIBITION

30924 ADJUSTMENT DISORDER WITH ANXIETY

30928 ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD

30929 ADJ REACT-EMOTION NEC

30981 POST TRAUMATIC STRESS DISORDER


F064 ANXIETY DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION

F419 ANXIETY DISORDER, UNSPECIFIED

F410 PANIC DISORDER [EPISODIC PAROXYSMAL ANXIETY] WITHOUT

AGORAPHOBIA

F411 GENERALIZED ANXIETY DISORDER

F413 OTHER MIXED ANXIETY DISORDERS

F418 OTHER SPECIFIED ANXIETY DISORDERS

F409 PHOBIC ANXIETY DISORDER, UNSPECIFIED

F4001 AGORAPHOBIA WITH PANIC DISORDER

F4002 AGORAPHOBIA WITHOUT PANIC DISORDER

F4000 AGORAPHOBIA, UNSPECIFIED

F4011 SOCIAL PHOBIA, GENERALIZED

F4010 SOCIAL PHOBIA, UNSPECIFIED

F40218 OTHER ANIMAL TYPE PHOBIA

F40230 FEAR OF BLOOD

F40210 ARACHNOPHOBIA

F40233 FEAR OF INJURY

F40220 FEAR OF THUNDERSTORMS

F40228 OTHER NATURAL ENVIRONMENT TYPE PHOBIA

F40242 FEAR OF BRIDGES

F40231 FEAR OF INJECTIONS AND TRANSFUSIONS

F40232 FEAR OF OTHER MEDICAL CARE

F40290 ANDROPHOBIA

F40240 CLAUSTROPHOBIA

F40241 ACROPHOBIA

F408 OTHER PHOBIC ANXIETY DISORDERS

F40243 FEAR OF FLYING

F40248 OTHER SITUATIONAL TYPE PHOBIA

F40291 GYNEPHOBIA






F40298 OTHER SPECIFIED PHOBIA

Anxiolytic Agents

History of prior therapy in the last 30, 60, or 180 days


Look back timeframe: 60, 90, or 200 days

Label Name GCN

ALPRAZOLAM 0.25 MG ODT 24368

ALPRAZOLAM 0.25 MG TABLET 14260

ALPRAZOLAM 0.5 MG ODT 24369

ALPRAZOLAM 0.5 MG TABLET 14261

ALPRAZOLAM 1 MG ODT 24373

ALPRAZOLAM 1 MG TABLET 14262

ALPRAZOLAM 1 MG/ML ORAL CONC 14264

ALPRAZOLAM 2 MG ODT 24374

ALPRAZOLAM 2 MG TABLET 14263

ALPRAZOLAM ER 0.5 MG TABLET 17423

ALPRAZOLAM ER 1 MG TABLET 17424



ALPRAZOLAM XR 0.5 MG TABLET 17423

ALPRAZOLAM XR 1 MG TABLET 17424















Anxiolytic Agents




Label Name GCN






























DIAZEPAM 5 MG/ML VIAL 14210




KLONOPIN WAFERS 0.125 MG 19467



Anxiolytic Agents




Label Name GCN



KLONOPIN WAFERS 1 MG ODT 19470

KLONOPIN WAFERS 2 MG 19472

LIBRIUM 5 MG CAPSULE 14033










MEBARAL 32 MG TABLET 17482



MEPHOBARBITAL 32 MG TABLET 17482





NIRAVAM 0.25 MG TABLET 24368

NIRAVAM 0.5 MG TABLET 24369

NIRAVAM 1 MG TABLET 24373

NIRAVAM 2 MG TABLET 24374




SERAX 15 MG CAPSULE 14231

SERAX 30 MG CAPSULE 14232






Anxiolytic Agents




Label Name GCN



VALIUM 2 MG TABLET 14221



VALIUM 5 MG/ML VIAL 14210

VANSPAR 7.5 MG TABLET 13037

XANAX 0.25 MG TABLET 14260

XANAX 0.5 MG TABLET 14261

XANAX 1 MG TABLET 14262

XANAX 2 MG TABLET 14263

XANAX XR 0.5 MG TABLET 17423

XANAX XR 1 MG TABLET 17424





Buspirone Agents




Label Name GCN










VANSPAR 7.5 MG TABLET 13037

Chloral Hydrate and Butabarbital Agents




Label Name GCN






Chlordiazepoxide, Meprobamate, and Oxazepam Agents




Label Name GCN








Chlordiazepoxide, Meprobamate, and Oxazepam Agents




Label Name GCN




Chronic Sleep Disorder Diagnoses


Look back timeframe: 365 or 730 days


30740 NONORGANIC SLEEP DIS NOS

30742 PERSISTENT INSOMNIA

30745 CIRCADIAN RHYTHM SLEEP DISORDER OF NONORGANIC ORIGIN

32700 ORGANIC INSOMNIA, UNSPECIFIED

32701 INSOMNIA DUE TO MEDICAL CONDITION CLASSIFIED ELSEWHERE

32702 INSOMNIA DUE TO MENTAL DISORDER

32709 OTHER ORGANIC INSOMNIA

78050 SLEEP DISTURBANCE NOS

78052 INSOMNIA, UNSPECIFIED

78055 DISRUPTION OF 24 HOUR SLEEP WAKE CYCLE, UNSPECIFIED


F519 SLEEP DISORDER NOT DUE TO A SUBSTANCE OR KNOWN

PHYSIOLOGICAL CONDITION, UNSPECIFIED

F5101 PRIMARY INSOMNIA

F5103 PARADOXICAL INSOMNIA

F5109 OTHER INSOMNIA NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION

G4701 INSOMNIA DUE TO MEDICAL CONDITION

F5105 INSOMNIA DUE TO OTHER MENTAL DISORDER

F5104 PSYCHOPHYSIOLOGIC INSOMNIA

G4709 OTHER INSOMNIA

G479 SLEEP DISORDER, UNSPECIFIED

G4700 INSOMNIA, UNSPECIFIED



Clonazepam and Diazepam Agents

History of prior therapy in the past 90 days



Label Name GCN




CLONAZEPAM 0.25 MG ODT 19468

CLONAZEPAM 2 MG ODT 19472







DIAZEPAM 5-7.5-10 MG GEL KIT 25598











Clorazepate Agents




Label Name GCN









Clorazepate Agents




Label Name GCN



Drug Abuse Diagnoses




30400 OPIOID DEPENDENCE-UNSPEC

30401 OPIOID DEPENDENCE-CONTIN

30402 OPIOID DEPENDENCE-EPISOD

30403 OPIOID DEPENDENCE-REMISS

30410 SEDATIVE,HYPNOTIC OR ANXIOLYTIC DEPENDENCE UNSPECIFIED

30411 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, CONTINUOUS

30412 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, EPISODIC

30413 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, IN REMISSION

30420 COCAINE DEPEND-UNSPEC

30421 COCAINE DEPEND-CONTIN

30422 COCAINE DEPEND-EPISODIC

30423 COCAINE DEPEND-REMISS

30430 CANNABIS DEPEND-UNSPEC

30431 CANNABIS DEPEND-CONTIN

30432 CANNABIS DEPEND-EPISODIC

30433 CANNABIS DEPEND-REMISS

30440 AMPHETAMIN DEPEND-UNSPEC

30441 AMPHETAMIN DEPEND-CONTIN

30442 AMPHETAMIN DEPEND-EPISOD

30443 AMPHETAMIN DEPEND-REMISS

30450 HALLUCINOGEN DEP-UNSPEC

30451 HALLUCINOGEN DEP-CONTIN

30452 HALLUCINOGEN DEP-EPISOD

30453 HALLUCINOGEN DEP-REMISS

30460 DRUG DEPEND NEC-UNSPEC






30461 DRUG DEPEND NEC-CONTIN

30462 DRUG DEPEND NEC-EPISODIC

30463 DRUG DEPEND NEC-IN REM

30470 OPIOID/OTHER DEP-UNSPEC

30471 OPIOID/OTHER DEP-CONTIN

30472 OPIOID/OTHER DEP-EPISOD

30473 OPIOID/OTHER DEP-REMISS

30480 COMB DRUG DEP NEC-UNSPEC

30481 COMB DRUG DEP NEC-CONTIN

30482 COMB DRUG DEP NEC-EPISOD

30483 COMB DRUG DEP NEC-REMISS

30490 DRUG DEPEND NOS-UNSPEC

30491 DRUG DEPEND NOS-CONTIN

30492 DRUG DEPEND NOS-EPISODIC

30493 DRUG DEPEND NOS-REMISS

30500 ALCOHOL ABUSE-UNSPEC

30501 ALCOHOL ABUSE-CONTINUOUS

30502 ALCOHOL ABUSE-EPISODIC

30503 ALCOHOL ABUSE-IN REMISS

30520 CANNABIS ABUSE-UNSPEC

30521 CANNABIS ABUSE-CONTIN

30522 CANNABIS ABUSE-EPISODIC

30523 CANNABIS ABUSE-IN REMISS

30530 HALLUCINOG ABUSE-UNSPEC

30531 HALLUCINOG ABUSE-CONTIN

30532 HALLUCINOG ABUSE-EPISOD

30533 HALLUCINOG ABUSE-REMISS

30540 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNSPECIFIED

30541 SEDATIVE, HYPNOTIC OR ANXIOLYTIC, ABUSE, CONTINUOUS

30542 SEDATIVE, HYPNOTIC, OR ANXIOLYTIC ABUSE, EPISODIC

30543 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, IN REMISSION

30550 OPIOID ABUSE-UNSPEC

30551 OPIOID ABUSE-CONTINUOUS

30552 OPIOID ABUSE-EPISODIC

30553 OPIOID ABUSE-IN REMISS

30560 COCAINE ABUSE-UNSPEC






30561 COCAINE ABUSE-CONTINUOUS

30562 COCAINE ABUSE-EPISODIC

30563 COCAINE ABUSE-IN REMISS

30570 AMPHETAMINE ABUSE-UNSPEC

30571 AMPHETAMINE ABUSE-CONTIN

30572 AMPHETAMINE ABUSE-EPISOD

30573 AMPHETAMINE ABUSE-REMISS

30580 ANTIDEPRESS ABUSE-UNSPEC

30581 ANTIDEPRESS ABUSE-CONTIN

30582 ANTIDEPRESS ABUSE-EPISOD

30583 ANTIDEPRESS ABUSE-REMISS

30590 DRUG ABUSE NEC-UNSPEC

30591 DRUG ABUSE NEC-CONTIN

30592 DRUG ABUSE NEC-EPISODIC

30593 DRUG ABUSE NEC-IN REMISS


F1129 OPIOID DEPENDENCE WITH UNSPECIFIED OPIOID-INDUCED

DISORDER

F1124 OPIOID DEPENDENCE WITH OPIOID-INDUCED MOOD DISORDER

F11282 OPIOID DEPENDENCE WITH OPIOID-INDUCED SLEEP DISORDER

F11288 OPIOID DEPENDENCE WITH OTHER OPIOID-INDUCED DISORDER

F11229 OPIOID DEPENDENCE WITH INTOXICATION, UNSPECIFIED

F11259 OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED

F11281 OPIOID DEPENDENCE WITH OPIOID-INDUCED SEXUAL DYSFUNCTION

F11221 OPIOID DEPENDENCE WITH INTOXICATION DELIRIUM

F11250 OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC DISORDER

WITH DELUSIONS

F11251 OPIOID DEPENDENCE WITH OPIOID-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS

F1123 OPIOID DEPENDENCE WITH WITHDRAWAL

F11222 OPIOID DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL

DISTURBANCE

F11220 OPIOID DEPENDENCE WITH INTOXICATION, UNCOMPLICATED

F1120 OPIOID DEPENDENCE, UNCOMPLICATED

F1121 OPIOID DEPENDENCE, IN REMISSION

F13288 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH OTHER

SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED DISORDER






F13280 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED ANXIETY DISORDER

F13281 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SEXUAL DYSFUNCTION

F13282 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED SLEEP DISORDER

F13259 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED

F1326 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE,

HYPNOTIC OR ANXIOLYTIC-INDUCED PERSISTING AMNESTIC DISORDER

F1329 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH

UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED DISORDER


HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS


HYPNOTIC OR ANXIOLYTIC-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS

F13232 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL WITH PERCEPTUAL DISTURBANCE

F13239 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL, UNSPECIFIED

F1327 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED PERSISTING DEMENTIA

F13230 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL, UNCOMPLICATED

F13231 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH WITHDRAWAL DELIRIUM

F13220 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION, UNCOMPLICATED

F13221 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH INTOXICATION DELIRIUM

F1324 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH SEDATIVE, HYPNOTIC OR ANXIOLYTIC-INDUCED MOOD DISORDER

F13229 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE WITH

INTOXICATION, UNSPECIFIED

F1320 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE,

UNCOMPLICATED

F1321 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, IN REMISSION

F14251 COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS

F14288 COCAINE DEPENDENCE WITH OTHER COCAINE-INDUCED DISORDER






F1429 COCAINE DEPENDENCE WITH UNSPECIFIED COCAINE-INDUCED DISORDER

F14281 COCAINE DEPENDENCE WITH COCAINE-INDUCED SEXUAL DYSFUNCTION

F14282 COCAINE DEPENDENCE WITH COCAINE-INDUCED SLEEP DISORDER

F14222 COCAINE DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE

F14259 COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED

F14280 COCAINE DEPENDENCE WITH COCAINE-INDUCED ANXIETY DISORDER

F1424 COCAINE DEPENDENCE WITH COCAINE-INDUCED MOOD DISORDER

F14250 COCAINE DEPENDENCE WITH COCAINE-INDUCED PSYCHOTIC

DISORDER WITH DELUSIONS

F14229 COCAINE DEPENDENCE WITH INTOXICATION, UNSPECIFIED

F1423 COCAINE DEPENDENCE WITH WITHDRAWAL

F14220 COCAINE DEPENDENCE WITH INTOXICATION, UNCOMPLICATED

F14221 COCAINE DEPENDENCE WITH INTOXICATION DELIRIUM

F1420 COCAINE DEPENDENCE, UNCOMPLICATED

F1421 COCAINE DEPENDENCE, IN REMISSION

F12251 CANNABIS DEPENDENCE WITH PSYCHOTIC DISORDER WITH

HALLUCINATIONS

F12288 CANNABIS DEPENDENCE WITH OTHER CANNABIS-INDUCED

DISORDER

F1229 CANNABIS DEPENDENCE WITH UNSPECIFIED CANNABIS-INDUCED

DISORDER

F12220 CANNABIS DEPENDENCE WITH INTOXICATION, UNCOMPLICATED

F12259 CANNABIS DEPENDENCE WITH PSYCHOTIC DISORDER, UNSPECIFIED

F12280 CANNABIS DEPENDENCE WITH CANNABIS-INDUCED ANXIETY DISORDER

F12222 CANNABIS DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE

F12229 CANNABIS DEPENDENCE WITH INTOXICATION, UNSPECIFIED

F12250 CANNABIS DEPENDENCE WITH PSYCHOTIC DISORDER WITH DELUSIONS

F1220 CANNABIS DEPENDENCE, UNCOMPLICATED

F12221 CANNABIS DEPENDENCE WITH INTOXICATION DELIRIUM

F1221 CANNABIS DEPENDENCE, IN REMISSION

F15220 OTHER STIMULANT DEPENDENCE WITH INTOXICATION, UNCOMPLICATED

F1520 OTHER STIMULANT DEPENDENCE, UNCOMPLICATED






F15222 OTHER STIMULANT DEPENDENCE WITH INTOXICATION WITH PERCEPTUAL DISTURBANCE

F1524 OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED MOOD DISORDER

F15221 OTHER STIMULANT DEPENDENCE WITH INTOXICATION DELIRIUM

F15251 OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS

F15229 OTHER STIMULANT DEPENDENCE WITH INTOXICATION, UNSPECIFIED

F1523 OTHER STIMULANT DEPENDENCE WITH WITHDRAWAL

F15281 OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED SEXUAL DYSFUNCTION

F15250 OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED

PSYCHOTIC DISORDER WITH DELUSIONS


PSYCHOTIC DISORDER, UNSPECIFIED


ANXIETY DISORDER

F1529 OTHER STIMULANT DEPENDENCE WITH UNSPECIFIED STIMULANT-

INDUCED DISORDER

F15282 OTHER STIMULANT DEPENDENCE WITH STIMULANT-INDUCED SLEEP DISORDER

F15288 OTHER STIMULANT DEPENDENCE WITH OTHER STIMULANT-INDUCED DISORDER

F1521 OTHER STIMULANT DEPENDENCE, IN REMISSION

F1629 HALLUCINOGEN DEPENDENCE WITH UNSPECIFIED HALLUCINOGEN-

INDUCED DISORDER

F16280 HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED

ANXIETY DISORDER

F16283 HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN PERSISTING PERCEPTION DISORDER (FLASHBACKS)

F16288 HALLUCINOGEN DEPENDENCE WITH OTHER HALLUCINOGEN-INDUCED DISORDER

F16251 HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS

F16259 HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED

F16229 HALLUCINOGEN DEPENDENCE WITH INTOXICATION, UNSPECIFIED

F1624 HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED MOOD DISORDER

F16250 HALLUCINOGEN DEPENDENCE WITH HALLUCINOGEN-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS

F16220 HALLUCINOGEN DEPENDENCE WITH INTOXICATION, UNCOMPLICATED

F16221 HALLUCINOGEN DEPENDENCE WITH INTOXICATION WITH DELIRIUM






F1620 HALLUCINOGEN DEPENDENCE, UNCOMPLICATED

F1621 HALLUCINOGEN DEPENDENCE, IN REMISSION

F1929 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH UNSPECIFIED

PSYCHOACTIVE SUBSTANCE-INDUCED DISORDER

F19281 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH

PSYCHOACTIVE SUBSTANCE-INDUCED SEXUAL DYSFUNCTION


PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC DISORDER WITH HALLUCINATIONS


PSYCHOACTIVE SUBSTANCE-INDUCED SLEEP DISORDER

F19288 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH OTHER PSYCHOACTIVE SUBSTANCE-INDUCED DISORDER

F1927 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING DEMENTIA

F19280 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED ANXIETY DISORDER

F19231 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL DELIRIUM

F19259 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED

F1926 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PERSISTING AMNESTIC DISORDER

F1924 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED MOOD DISORDER

F19250 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH PSYCHOACTIVE SUBSTANCE-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS


INTOXICATION, UNCOMPLICATED

F19232 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL

WITH PERCEPTUAL DISTURBANCE


WITHDRAWAL, UNSPECIFIED


INTOXICATION WITH PERCEPTUAL DISTURBANCE

F19229 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION, UNSPECIFIED

F19230 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH WITHDRAWAL, UNCOMPLICATED

F1920 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE, UNCOMPLICATED






F19221 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE WITH INTOXICATION DELIRIUM

F18288 INHALANT DEPENDENCE WITH OTHER INHALANT-INDUCED DISORDER

F18280 INHALANT DEPENDENCE WITH INHALANT-INDUCED ANXIETY DISORDER

F18250 INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC DISORDER WITH DELUSIONS

F1829 INHALANT DEPENDENCE WITH UNSPECIFIED INHALANT-INDUCED DISORDER

F18259 INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC DISORDER, UNSPECIFIED

F1827 INHALANT DEPENDENCE WITH INHALANT-INDUCED DEMENTIA

F1824 INHALANT DEPENDENCE WITH INHALANT-INDUCED MOOD DISORDER

F18251 INHALANT DEPENDENCE WITH INHALANT-INDUCED PSYCHOTIC

DISORDER WITH HALLUCINATIONS

F18221 INHALANT DEPENDENCE WITH INTOXICATION DELIRIUM

F18220 INHALANT DEPENDENCE WITH INTOXICATION, UNCOMPLICATED

F18229 INHALANT DEPENDENCE WITH INTOXICATION, UNSPECIFIED

F1820 INHALANT DEPENDENCE, UNCOMPLICATED

F1921 OTHER PSYCHOACTIVE SUBSTANCE DEPENDENCE, IN REMISSION

F1821 INHALANT DEPENDENCE, IN REMISSION

F1010 ALCOHOL ABUSE, UNCOMPLICATED

F10129 ALCOHOL ABUSE WITH INTOXICATION, UNSPECIFIED

F10120 ALCOHOL ABUSE WITH INTOXICATION, UNCOMPLICATED

F1290 CANNABIS USE, UNSPECIFIED, UNCOMPLICATED

F1210 CANNABIS ABUSE, UNCOMPLICATED

F1610 HALLUCINOGEN ABUSE, UNCOMPLICATED

F1690 HALLUCINOGEN USE, UNSPECIFIED, UNCOMPLICATED

F16120 HALLUCINOGEN ABUSE WITH INTOXICATION, UNCOMPLICATED

F1310 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNCOMPLICATED

F1390 SEDATIVE, HYPNOTIC, OR ANXIOLYTIC USE, UNSPECIFIED,

UNCOMPLICATED

F13120 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE WITH INTOXICATION,

UNCOMPLICATED

F11120 OPIOID ABUSE WITH INTOXICATION, UNCOMPLICATED

F1110 OPIOID ABUSE, UNCOMPLICATED

F1190 OPIOID USE, UNSPECIFIED, UNCOMPLICATED

F11129 OPIOID ABUSE WITH INTOXICATION, UNSPECIFIED

F14120 COCAINE ABUSE WITH INTOXICATION, UNCOMPLICATED






F1490 COCAINE USE, UNSPECIFIED, UNCOMPLICATED

F1410 COCAINE ABUSE, UNCOMPLICATED

F1590 OTHER STIMULANT USE, UNSPECIFIED, UNCOMPLICATED

F1510 OTHER STIMULANT ABUSE, UNCOMPLICATED

F15120 OTHER STIMULANT ABUSE WITH INTOXICATION, UNCOMPLICATED

F554 ABUSE OF VITAMINS

F558 ABUSE OF OTHER NON-PSYCHOACTIVE SUBSTANCES

F552 ABUSE OF LAXATIVES

F553 ABUSE OF STEROIDS OR HORMONES

F550 ABUSE OF ANTACIDS

F551 ABUSE OF HERBAL OR FOLK REMEDIES

F18120 INHALANT ABUSE WITH INTOXICATION, UNCOMPLICATED

F1810 INHALANT ABUSE, UNCOMPLICATED

F1890 INHALANT USE, UNSPECIFIED, UNCOMPLICATED

Epilepsy Diagnoses




3452 PETIT MAL STATUS

3453 GRAND MAL STATUS

34500 GEN NONCV EP W/O INTR EP

34501 GEN NONCONV EP W INTR EP

34510 GEN CNV EPIL W/O INTR EP

34511 GEN CNV EPIL W INTR EPIL

34540 LOCALIZATION-RELATED (FOCAL) (PARTIAL) EPILEPSY AND EPILEPTIC SYNDROMES WITH COMPLEX PARTIAL SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY

34541 LOCALIZATION-RELATED (FOCAL) (PARTIAL) EPILEPSY AND EPILEPTIC SYNDROMES WITH COMPLEX PARTIAL SEIZURES, WITH INTRACTABLE EPILEPSY

34550 LOCALIZATION-RELATED (FOCAL) (PARTIAL) EPILEPSY AND EPILEPTIC SYNDROMES WITH SIMPLE PARTIAL SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY

34551 LOCALIZATION-RELATED (FOCAL) (PARTIAL) EPILEPSY AND EPILEPTIC SYNDROMES WITH SIMPLE PARTIAL SEIZURES, WITH INTRACTABLE EPILEPSY



Epilepsy Diagnoses



34560 INF SPASM W/O INTR EPIL

34561 INF SPASM W INTRACT EPIL

34570 EPIL PAR CONT W/O INT EP

34571 EPIL PAR CONT W INTR EPI

34580 OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT

MENTION OF INTRACTABLE EPILEPSY

34581 OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITH

INTRACTABLE EPILEPSY

34590 EPILEP NOS W/O INTR EPIL

34591 EPILEPSY NOS W INTR EPIL


G232 STRIATONIGRAL DEGENERATION

G238 OTHER SPECIFIED DEGENERATIVE DISEASES OF BASAL GANGLIA

G239 DEGENERATIVE DISEASE OF BASAL GANGLIA, UNSPECIFIED

G230 HALLERVORDEN-SPATZ DISEASE

G231 PROGRESSIVE SUPRANUCLEAR OPHTHALMOPLEGIA [STEELE-

RICHARDSON-OLSZEWSKI]

G903 MULTI-SYSTEM DEGENERATION OF THE AUTONOMIC NERVOUS

SYSTEM

G250 ESSENTIAL TREMOR

G251 DRUG-INDUCED TREMOR

G252 OTHER SPECIFIED FORMS OF TREMOR

G253 MYOCLONUS

G2569 OTHER TICS OF ORGANIC ORIGIN

G2561 DRUG INDUCED TICS

G10 HUNTINGTON'S DISEASE

G255 OTHER CHOREA

G254 DRUG-INDUCED CHOREA

G241 GENETIC TORSION DYSTONIA

G803 ATHETOID CEREBRAL PALSY

G2402 DRUG INDUCED ACUTE DYSTONIA

G2409 OTHER DRUG INDUCED DYSTONIA

G242 IDIOPATHIC NONFAMILIAL DYSTONIA

G248 OTHER DYSTONIA

G245 BLEPHAROSPASM

G244 IDIOPATHIC OROFACIAL DYSTONIA

G243 SPASMODIC TORTICOLLIS

G2589 OTHER SPECIFIED EXTRAPYRAMIDAL AND MOVEMENT DISORDERS

G2401 DRUG INDUCED SUBACUTE DYSKINESIA



Epilepsy Diagnoses



G249 DYSTONIA, UNSPECIFIED

G259 EXTRAPYRAMIDAL AND MOVEMENT DISORDER, UNSPECIFIED

G2582 STIFF-MAN SYNDROME

G210 MALIGNANT NEUROLEPTIC SYNDROME

G2583 BENIGN SHUDDERING ATTACKS

G2581 RESTLESS LEGS SYNDROME

G2571 DRUG INDUCED AKATHISIA

G26 EXTRAPYRAMIDAL AND MOVEMENT DISORDERS IN DISEASES

CLASSIFIED ELSEWHERE

G2579 OTHER DRUG INDUCED MOVEMENT DISORDERS

G2570 DRUG INDUCED MOVEMENT DISORDER, UNSPECIFIED

G35 MULTIPLE SCLEROSIS

G8100 FLACCID HEMIPLEGIA AFFECTING UNSPECIFIED SIDE

G8101 FLACCID HEMIPLEGIA AFFECTING RIGHT DOMINANT SIDE

G8102 FLACCID HEMIPLEGIA AFFECTING LEFT DOMINANT SIDE

G8103 FLACCID HEMIPLEGIA AFFECTING RIGHT NONDOMINANT SIDE

G8104 FLACCID HEMIPLEGIA AFFECTING LEFT NONDOMINANT SIDE

G8110 SPASTIC HEMIPLEGIA AFFECTING UNSPECIFIED SIDE

G8112 SPASTIC HEMIPLEGIA AFFECTING LEFT DOMINANT SIDE

G8111 SPASTIC HEMIPLEGIA AFFECTING RIGHT DOMINANT SIDE

G8114 SPASTIC HEMIPLEGIA AFFECTING LEFT NONDOMINANT SIDE

G8113 SPASTIC HEMIPLEGIA AFFECTING RIGHT NONDOMINANT SIDE

G8190 HEMIPLEGIA, UNSPECIFIED AFFECTING UNSPECIFIED SIDE

G8192 HEMIPLEGIA, UNSPECIFIED AFFECTING LEFT DOMINANT SIDE

G8191 HEMIPLEGIA, UNSPECIFIED AFFECTING RIGHT DOMINANT SIDE

G8194 HEMIPLEGIA, UNSPECIFIED AFFECTING LEFT NONDOMINANT SIDE

G8193 HEMIPLEGIA, UNSPECIFIED AFFECTING RIGHT NONDOMINANT SIDE

G801 SPASTIC DIPLEGIC CEREBRAL PALSY

G802 SPASTIC HEMIPLEGIC CEREBRAL PALSY

G800 SPASTIC QUADRIPLEGIC CEREBRAL PALSY

G808 OTHER CEREBRAL PALSY

G804 ATAXIC CEREBRAL PALSY

G809 CEREBRAL PALSY, UNSPECIFIED

G8250 QUADRIPLEGIA, UNSPECIFIED

G8251 QUADRIPLEGIA, C1-C4 COMPLETE

G8252 QUADRIPLEGIA, C1-C4 INCOMPLETE





Epilepsy Diagnoses



G041 TROPICAL SPASTIC PARAPLEGIA

G8220 PARAPLEGIA, UNSPECIFIED

G8221 PARAPLEGIA, COMPLETE

G8222 PARAPLEGIA, INCOMPLETE

G830 DIPLEGIA OF UPPER LIMBS

G8310 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE

G8312 MONOPLEGIA OF LOWER LIMB AFFECTING LEFT DOMINANT SIDE

G8311 MONOPLEGIA OF LOWER LIMB AFFECTING RIGHT DOMINANT SIDE

G8313 MONOPLEGIA OF LOWER LIMB AFFECTING RIGHT NONDOMINANT

SIDE

G8314 MONOPLEGIA OF LOWER LIMB AFFECTING LEFT NONDOMINANT SIDE

G8320 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE

G8321 MONOPLEGIA OF UPPER LIMB AFFECTING RIGHT DOMINANT SIDE

G8322 MONOPLEGIA OF UPPER LIMB AFFECTING LEFT DOMINANT SIDE

G8324 MONOPLEGIA OF UPPER LIMB AFFECTING LEFT NONDOMINANT SIDE

G8323 MONOPLEGIA OF UPPER LIMB AFFECTING RIGHT NONDOMINANT SIDE

G8332 MONOPLEGIA, UNSPECIFIED AFFECTING LEFT DOMINANT SIDE

G8330 MONOPLEGIA, UNSPECIFIED AFFECTING UNSPECIFIED SIDE

G8331 MONOPLEGIA, UNSPECIFIED AFFECTING RIGHT DOMINANT SIDE

G8333 MONOPLEGIA, UNSPECIFIED AFFECTING RIGHT NONDOMINANT SIDE

G8334 MONOPLEGIA, UNSPECIFIED AFFECTING LEFT NONDOMINANT SIDE

G834 CAUDA EQUINA SYNDROME

G835 LOCKED-IN STATE

G8383 POSTERIOR CORD SYNDROME

G8384 TODD'S PARALYSIS (POSTEPILEPTIC)

G8389 OTHER SPECIFIED PARALYTIC SYNDROMES

G8381 BROWN-SEQUARD SYNDROME

G8382 ANTERIOR CORD SYNDROME

G839 PARALYTIC SYNDROME, UNSPECIFIED

Flurazepam Agents




Description GCN





Insomnia Diagnoses




30742 PERSISTENT INSOMNIA

32701 INSOMNIA DUE TO MEDICAL CONDITION CLASSIFIED ELSEWHERE

32702 INSOMNIA DUE TO MENTAL DISORDER



F5103 PARADOXICAL INSOMNIA

F5109 OTHER INSOMNIA NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION


G4701 INSOMNIA DUE TO MEDICAL CONDITION

F5105 INSOMNIA DUE TO OTHER MENTAL DISORDER

F5104 PSYCHOPHYSIOLOGIC INSOMNIA

Lorazepam Agents




Label Name GCN















Muscle Disorder Diagnoses




340 MULTIPLE SCLEROSIS

3330 DEGEN BASAL GANGLIA NEC

3331 TREMOR NEC

3332 MYOCLONUS

3333 TICS OF ORGANIC ORIGIN

3334 HUNTINGTON'S CHOREA

3335 CHOREA NEC

3336 GENETIC TORSION DYSTONIA

3337 SYMPTOM TORSION DYSTONIA

3430 CONGENITAL DIPLEGIA

3431 CONGENITAL HEMIPLEGIA

3432 CONGENITAL QUADRIPLEGIA

3433 CONGENITAL MONOPLEGIA

3434 INFANTILE HEMIPLEGIA

3438 CEREBRAL PALSY NEC

3439 CEREBRAL PALSY NOS

3441 PARAPLEGIA NOS

3442 DIPLEGIA OF UPPER LIMBS

3445 MONOPLEGIA NOS

3449 PARALYSIS NOS

3592 MYOTONIC DISORDERS

7810 ABN INVOLUN MOVEMENT NEC

7817 TETANY

8052 FX DORSAL VERTEBRA-CLOSE

8053 FX DORSAL VERTEBRA-OPEN

8054 FX LUMBAR VERTEBRA-CLOSE

8055 FX LUMBAR VERTEBRA-OPEN

8056 FX SACRUM/COCCYX-CLOSED

8057 FX SACRUM/COCCYX-OPEN

8058 VERTEBRAL FX NOS-CLOSED

8059 VERTEBRAL FX NOS-OPEN

8064 CL LUMBAR FX W CORD INJ

8065 OPN LUMBAR FX W CORD INJ

8068 VERT FX NOS-CL W CRD INJ

8069 VERT FX NOS-OP W CRD INJ

9072 LATE EFF SPINAL CORD INJ






9522 LUMBAR SPINAL CORD INJUR

9523 SACRAL SPINAL CORD INJUR

9524 CAUDA EQUINA INJURY

9528 SPIN CORD INJ-MULT SITE

9529 SPINAL CORD INJURY NOS

33371 ATHETOID CEREBRAL PALSY

33372 ACUTE DYSTONIA DUE TO DRUGS

33379 OTHER ACQUIRED TORSION DYSTONIA

33381 BLEPHAROSPASM

33382 OROFACIAL DYSKINESIA

33383 SPASMODIC TORTICOLLIS

33384 ORGANIC WRITERS' CRAMP

33385 SUBACUTE DYSKINESIA DUE TO DRUGS

33389 FRAGM TORSION DYSTON NEC

33390 EXTRAPYRAMIDAL DIS NOS

33391 STIFF-MAN SYNDROME

33392 NEUROLEPTIC MALGNT SYND

33393 BNIGN SHUDDERING ATTACKS

33394 RESTLESS LEGS SYNDROME

33399 EXTRAPYRAMIDAL DIS NEC

34200 FLCCD HMIPLGA UNSPF SIDE

34201 FLCCD HMIPLGA DOMNT SIDE

34202 FLCCD HMIPLG NONDMNT SDE

34210 SPSTC HMIPLGA UNSPF SIDE

34211 SPSTC HMIPLGA DOMNT SIDE

34212 SPSTC HMIPLG NONDMNT SDE

34280 OT SP HMIPLGA UNSPF SIDE

34281 OT SP HMIPLGA DOMNT SIDE

34282 OT SP HMIPLG NONDMNT SDE

34290 UNSP HEMIPLGA UNSPF SIDE

34291 UNSP HEMIPLGA DOMNT SIDE

34292 UNSP HMIPLGA NONDMNT SDE

34400 QUADRIPLEGIA, UNSPECIFD

34401 QUADRPLG C1-C4, COMPLETE

34402 QUADRPLG C1-C4, INCOMPLT

34403 QUADRPLG C5-C7, COMPLETE

34404 QUADRPLG C5-C7, INCOMPLT

34409 OTHER QUADRIPLEGIA






34430 MONPLGA LWR LMB UNSP SDE

34431 MONPLGA LWR LMB DMNT SDE

34432 MNPLG LWR LMB NONDMNT SD

34440 MONPLGA UPR LMB UNSP SDE

34441 MONPLGA UPR LMB DMNT SDE

34442 MNPLG UPR LMB NONDMNT SD

34460 CAUDA EQUINA SYND NOS

34461 NEUROGENIC BLADDER

34481 LOCKED-IN STATE

34489 OTH SPCF PARALYTIC SYND

35921 MYOTONIC MUSCULAR DYSTROPHY

35922 MYOTONIA CONGENITA

35923 MYOTONIC CHONDRODYSTROPHY

35924 DRUG INDUCED MYOTONIA

35929 OTHER SPECIFIED MYOTONIC DISORDER

72885 SPASM OF MUSCLE

80500 FX CERVICAL VERT NOS-CL

80501 FX C1 VERTEBRA-CLOSED







80508 FX MULT CERVICAL VERT-CL

80510 FX CERVICAL VERT NOS-OPN

80511 FX C1 VERTEBRA-OPEN







80518 FX MLT CERVICAL VERT-OPN

80600 C1-C4 FX-CL/CORD INJ NOS

80601 C1-C4 FX-CL/COM CORD LES

80602 C1-C4 FX-CL/ANT CORD SYN

80603 C1-C4 FX-CL/CEN CORD SYN






80604 C1-C4 FX-CL/CORD INJ NEC

80605 C5-C7 FX-CL/CORD INJ NOS

80606 C5-C7 FX-CL/COM CORD LES

80607 C5-C7 FX-CL/ANT CORD SYN

80608 C5-C7 FX-CL/CEN CORD SYN

80609 C5-C7 FX-CL/CORD INJ NEC

80610 C1-C4 FX-OP/CORD INJ NOS

80611 C1-C4 FX-OP/COM CORD LES

80612 C1-C4 FX-OP/ANT CORD SYN

80613 C1-C4 FX-OP/CEN CORD SYN

80614 C1-C4 FX-OP/CORD INJ NEC

80615 C5-C7 FX-OP/CORD INJ NOS

80616 C5-C7 FX-OP/COM CORD LES

80617 C5-C7 FX-OP/ANT CORD SYN

80618 C5-C7 FX-OP/CEN CORD SYN

80619 C5-C7 FX-OP/CORD INJ NEC

80620 T1-T6 FX-CL/CORD INJ NOS

80621 T1-T6 FX-CL/COM CORD LES

80622 T1-T6 FX-CL/ANT CORD SYN

80623 T1-T6 FX-CL/CEN CORD SYN

80624 T1-T6 FX-CL/CORD INJ NEC

80625 T7-T12 FX-CL/CRD INJ NOS

80626 T7-T12 FX-CL/COM CRD LES

80627 T7-T12 FX-CL/ANT CRD SYN

80628 T7-T12 FX-CL/CEN CRD SYN

80629 T7-T12 FX-CL/CRD INJ NEC

80630 T1-T6 FX-OP/CORD INJ NOS

80631 T1-T6 FX-OP/COM CORD LES

80632 T1-T6 FX-OP/ANT CORD SYN

80633 T1-T6 FX-OP/CEN CORD SYN

80634 T1-T6 FX-OP/CORD INJ NEC

80635 T7-T12 FX-OP/CRD INJ NOS

80636 T7-T12 FX-OP/COM CRD LES

80637 T7-T12 FX-OP/ANT CRD SYN

80638 T7-T12 FX-OP/CEN CRD SYN

80639 T7-T12 FX-OP/CRD INJ NEC

80660 FX SACRUM-CL/CRD INJ NOS

80661 FX SACR-CL/CAUDA EQU LES






80662 FX SACR-CL/CAUDA INJ NEC

80669 FX SACRUM-CL/CRD INJ NEC

80670 FX SACRUM-OP/CRD INJ NOS

80671 FX SACR-OP/CAUDA EQU LES

80672 FX SACR-OP/CAUDA INJ NEC

80679 FX SACRUM-OP/CRD INJ NEC

95200 C1-C4 SPIN CORD INJ NOS

95201 COMPLETE LES CORD/C1-C4

95202 ANTERIOR CORD SYND/C1-C4

95203 CENTRAL CORD SYND/C1-C4

95204 C1-C4 SPIN CORD INJ NEC

95205 C5-C7 SPIN CORD INJ NOS

95206 COMPLETE LES CORD/C5-C7

95207 ANTERIOR CORD SYND/C5-C7

95208 CENTRAL CORD SYND/C5-C7

95209 C5-C7 SPIN CORD INJ NEC

95210 T1-T6 SPIN CORD INJ NOS

95211 COMPLETE LES CORD/T1-T6

95212 ANTERIOR CORD SYND/T1-T6

95213 CENTRAL CORD SYND/T1-T6

95214 T1-T6 SPIN CORD INJ NEC

95215 T7-T12 SPIN CORD INJ NOS

95216 COMPLETE LES CORD/T7-T12

95217 ANTERIOR CORD SYN/T7-T12

95218 CENTRAL CORD SYN/T7-T12

95219 T7-T12 SPIN CORD INJ NEC


G232 STRIATONIGRAL DEGENERATION

G238 OTHER SPECIFIED DEGENERATIVE DISEASES OF BASAL GANGLIA

G239 DEGENERATIVE DISEASE OF BASAL GANGLIA, UNSPECIFIED

G230 HALLERVORDEN-SPATZ DISEASE

G231 PROGRESSIVE SUPRANUCLEAR OPHTHALMOPLEGIA [STEELE-RICHARDSON-OLSZEWSKI]

G903 MULTI-SYSTEM DEGENERATION OF THE AUTONOMIC NERVOUS SYSTEM

G250 ESSENTIAL TREMOR

G251 DRUG-INDUCED TREMOR

G252 OTHER SPECIFIED FORMS OF TREMOR

G253 MYOCLONUS






G2569 OTHER TICS OF ORGANIC ORIGIN

G2561 DRUG INDUCED TICS

G10 HUNTINGTON'S DISEASE

G255 OTHER CHOREA

G254 DRUG-INDUCED CHOREA

G241 GENETIC TORSION DYSTONIA

G803 ATHETOID CEREBRAL PALSY

G2402 DRUG INDUCED ACUTE DYSTONIA

G2409 OTHER DRUG INDUCED DYSTONIA

G242 IDIOPATHIC NONFAMILIAL DYSTONIA

G248 OTHER DYSTONIA

G245 BLEPHAROSPASM

G244 IDIOPATHIC OROFACIAL DYSTONIA

G243 SPASMODIC TORTICOLLIS

G2589 OTHER SPECIFIED EXTRAPYRAMIDAL AND MOVEMENT DISORDERS

G2401 DRUG INDUCED SUBACUTE DYSKINESIA

G249 DYSTONIA, UNSPECIFIED

G259 EXTRAPYRAMIDAL AND MOVEMENT DISORDER, UNSPECIFIED

G2582 STIFF-MAN SYNDROME

G210 MALIGNANT NEUROLEPTIC SYNDROME

G2583 BENIGN SHUDDERING ATTACKS

G2581 RESTLESS LEGS SYNDROME

G2571 DRUG INDUCED AKATHISIA

G26 EXTRAPYRAMIDAL AND MOVEMENT DISORDERS IN DISEASES CLASSIFIED ELSEWHERE

G2579 OTHER DRUG INDUCED MOVEMENT DISORDERS

G2570 DRUG INDUCED MOVEMENT DISORDER, UNSPECIFIED

G35 MULTIPLE SCLEROSIS

G8100 FLACCID HEMIPLEGIA AFFECTING UNSPECIFIED SIDE

G8101 FLACCID HEMIPLEGIA AFFECTING RIGHT DOMINANT SIDE

G8102 FLACCID HEMIPLEGIA AFFECTING LEFT DOMINANT SIDE

G8103 FLACCID HEMIPLEGIA AFFECTING RIGHT NONDOMINANT SIDE

G8104 FLACCID HEMIPLEGIA AFFECTING LEFT NONDOMINANT SIDE

G8110 SPASTIC HEMIPLEGIA AFFECTING UNSPECIFIED SIDE

G8112 SPASTIC HEMIPLEGIA AFFECTING LEFT DOMINANT SIDE

G8111 SPASTIC HEMIPLEGIA AFFECTING RIGHT DOMINANT SIDE

G8114 SPASTIC HEMIPLEGIA AFFECTING LEFT NONDOMINANT SIDE

G8113 SPASTIC HEMIPLEGIA AFFECTING RIGHT NONDOMINANT SIDE

G8190 HEMIPLEGIA, UNSPECIFIED AFFECTING UNSPECIFIED SIDE






G8192 HEMIPLEGIA, UNSPECIFIED AFFECTING LEFT DOMINANT SIDE

G8191 HEMIPLEGIA, UNSPECIFIED AFFECTING RIGHT DOMINANT SIDE

G8194 HEMIPLEGIA, UNSPECIFIED AFFECTING LEFT NONDOMINANT SIDE

G8193 HEMIPLEGIA, UNSPECIFIED AFFECTING RIGHT NONDOMINANT SIDE

G801 SPASTIC DIPLEGIC CEREBRAL PALSY

G802 SPASTIC HEMIPLEGIC CEREBRAL PALSY

G800 SPASTIC QUADRIPLEGIC CEREBRAL PALSY

G808 OTHER CEREBRAL PALSY

G804 ATAXIC CEREBRAL PALSY

G809 CEREBRAL PALSY, UNSPECIFIED

G8250 QUADRIPLEGIA, UNSPECIFIED





G041 TROPICAL SPASTIC PARAPLEGIA

G8220 PARAPLEGIA, UNSPECIFIED

G8221 PARAPLEGIA, COMPLETE

G8222 PARAPLEGIA, INCOMPLETE

G830 DIPLEGIA OF UPPER LIMBS

G8310 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE

G8312 MONOPLEGIA OF LOWER LIMB AFFECTING LEFT DOMINANT SIDE

G8311 MONOPLEGIA OF LOWER LIMB AFFECTING RIGHT DOMINANT SIDE

G8313 MONOPLEGIA OF LOWER LIMB AFFECTING RIGHT NONDOMINANT SIDE

G8314 MONOPLEGIA OF LOWER LIMB AFFECTING LEFT NONDOMINANT SIDE

G8320 MONOPLEGIA OF UPPER LIMB AFFECTING UNSPECIFIED SIDE

G8321 MONOPLEGIA OF UPPER LIMB AFFECTING RIGHT DOMINANT SIDE

G8322 MONOPLEGIA OF UPPER LIMB AFFECTING LEFT DOMINANT SIDE

G8324 MONOPLEGIA OF UPPER LIMB AFFECTING LEFT NONDOMINANT SIDE

G8323 MONOPLEGIA OF UPPER LIMB AFFECTING RIGHT NONDOMINANT SIDE

G8332 MONOPLEGIA, UNSPECIFIED AFFECTING LEFT DOMINANT SIDE

G8330 MONOPLEGIA, UNSPECIFIED AFFECTING UNSPECIFIED SIDE

G8331 MONOPLEGIA, UNSPECIFIED AFFECTING RIGHT DOMINANT SIDE

G8333 MONOPLEGIA, UNSPECIFIED AFFECTING RIGHT NONDOMINANT SIDE

G8334 MONOPLEGIA, UNSPECIFIED AFFECTING LEFT NONDOMINANT SIDE

G834 CAUDA EQUINA SYNDROME

G835 LOCKED-IN STATE






G8383 POSTERIOR CORD SYNDROME

G8384 TODD'S PARALYSIS (POSTEPILEPTIC)

G8389 OTHER SPECIFIED PARALYTIC SYNDROMES

G8381 BROWN-SEQUARD SYNDROME

G8382 ANTERIOR CORD SYNDROME

G839 PARALYTIC SYNDROME, UNSPECIFIED

Panic Disorder or GAD Diagnosis




30000 ANXIETY STATE NOS

30001 PANIC DISORDER WITHOUT AGORAPHOBIA

30002 GENERALIZED ANXIETY DIS

30009 ANXIETY STATE NEC


F41.9 ANXIETY DISORDER, UNSPECIFIED

F41.0 PANIC DISORDER [EPISODIC PAROXYSMAL ANXIETY] WITHOUT

AGORAPHOBIA

F41.1 GENERALIZED ANXIETY DISORDER

F41.8 OTHER SPECIFIED ANXIETY DISORDERS

Ramelteon Agents




Label Name GCN




Sedative/Hypnotic Agents

History of prior therapy in the past 30 or 90 days



Label Name GCN









DORAL 15 MG TABLET 40870







HALCION 0.25 MG TABLET 14280





















Sedative/Hypnotic Agents

History of prior therapy in the past 30 or 90 days



Label Name GCN






History of an SSRI or SNRI

Required number of claims: 1


GCN Description

34876 BRISDELLE 7.5MG CAPSULE

16345 CELEXA 10MG TABLET



16345 CITALOPRAM HBR 10MG TABLET

16344 CITALOPRAM HBR 10MG/5ML SOLUTION



23161 CYMBALTA 20MG CAPSULE

23162 CYMBALTA 30MG CAPSULE

23164 CYMPALTA 60MG CAPSULE

34482 DESVENLAFAXINE ER 100MG TABLET




23161 DULOXETINE HCL DR 20MG CAPSULE



16818 EFFEXOR XR 150MG CAPSULE

16816 EFFEXOR XR 37.5MG CAPSULE

16817 EFFEXOR XR 75MG CAPSULE

17851 ESCITALOPRAM 10MG TABLET







GCN Description


19035 ESCITALOPRAM 5MG/5ML SOLUTION

35335 FETZIMA 20-40MG TITRATION PAK

35334 FETZIMA ER 120MG CAPSULE




16357 FLUOXETINE 20MG/5ML SOLUTION

12929 FLUOXETINE DR 90MG CAPSULE

16353 FLUOXETINE HCL 10MG CAPSULE

16356 FLUOXETINE HCL 10MG TABLET





99481 FLUVOXAMINE ER 100MG CAPSULE

99482 FLUVOXAMINE ER 150MG CAPSULE

16349 FLUVOXAMINE MALEATE 100MG TABLET



35584 KHEDEZLA ER 100MG TABLET

35582 KHEDEZLA ER 50MG TABLET

17851 LEXAPRO 10MG TABLET



19035 LEXAPRO 5MG/5ML SOLUTION

99481 LUVOX CR 100MG CAPSULE

99482 LUVOX CR 150MG CAPSULE

17078 PAROXETINE CR 12.5MG TABLET

17077 PAROXETINE CR 25MG TABLET

17079 PAROXETINE CR 37.5MG TABLET

16364 PAROXETINE HCL 10MG TABLET









GCN Description

16364 PAXIL 10MG TABLET

16369 PAXIL 10MG/5ML SUSPENSION




17078 PAXIL CR 12.5MG TABLET

17077 PAXIL CR 25MG TABLET

17079 PAXIL CR 37.5MG TABLET

20854 PEXEVA 10MG TABLET




99452 PRISTIQ ER 100MG TABLET

99451 PRISTIQ ER 50MG TABLET

16353 PROZAC 10MG PULVULE



12929 PROZAC WEEKLY 90MG CAPSULE

16376 SERTRALINE 20MG/ML ORAL CONCENTRATE

16375 SERTRALINE HCL 100MG TABLET



16815 VENLAFAXINE HCL 100MG TABLET


16812 VENLAFAXINE HCL 37.5MG TABLET



16818 VENLAFAXINE HCL ER 150MG CAPSULE

14353 VENLAFAXINE HCL ER 150MG TABLET


16816 VENLAFAXINE HCL ER 37.5MG CAPSULE

14349 VENLAFAXINE HCL ER 37.5MG TABLET

16817 VENLAFAXINE HCL ER 75MG CAPSULE


29916 VIIBRYD 10MG TABLET






GCN Description



31956 VIIBRYD TITRATION PACK

16375 ZOLOFT 100MG TABLET

16376 ZOLOFT 20MG/ML ORAL CONCENTRATE



Texas Prior Authorization Program Clinical Edits ASHs – Publication History



(ASHs)

Clinical Edit Criteria References

1. Silber MH. Chronic insomnia. N Eng J Med 2005; 353:803–10. 2. Witek MW, Rojas V, Alonso C, et al. Review of benzodiazepine use in children

and adolescents. Psychiatr Quart 2005; 76:283–96. 3. Davidson JRT. Pharmacotherapy of generalized anxiety disorder. J Clin

Psychiatry 2001; 62(suppl 11): 46–50. 4. Varley CK, Smith CJ. Anxiety disorders in the child and teen. Pediatr Clin N Am

2003; 50: 1107–38. 5. Pelayo R, Chen W, Monzon S, et al. Pediatric sleep pharmacology: You want to

give my kid sleeping pills? Pediatr Clin N Am 2004; 51:117–34. 6. Eddy M, Walbroehl GS. Insomnia. Am Fam Phys 1999;59(7): 1911–6. 7. Infante M, Benca R. Treatment of insomnia. Prim Psychiatry 2006; 12:47–56. 8. Zohar J. World Council on Anxiety recommendations for the long-term

treatment of anxiety. CNS Spectr 2003; 8:5–6. 9. Longo LP, Johnson B. Addiction: Part 1: Benzodiazepines- side effects, abuse

risk and alternatives. Am Fam Physician 2000 Apr 1; 61(7):2121–8. 10. American Academy of Child and Adolescent Psychiatry. Practice parameters for

the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 1997; 36(Suppl 10):1–30.

11. Demartinis N, Rynn M, Rickels K, Mandos L. Prior benzodiazepine use and

buspirone response in the treatment of generalized anxiety disorder. J Clin Psychiatry 2000; 61(2):91–4.

12. Owens JA, Babcock D, Blumer J, et al. The use of pharmacotherapy in the

treatment of pediatric insomnia in primary care: Rational approaches. A consensus meeting summary. J Clin Sleep Med 2005; 1:49–59.

13. Mindell JA, Emslie G, Blumer J, et al. Pharmacologic management of insomnia

in children and adolescents: Consensus Statement. Pediatrics 2006; 117:1223–32.

14. Owens J. Insomnia in children and adolescents. J Clin Sleep Med 2005; 1:454–

8.

15. Clinical Pharmacology [online database]. Tampa, FL: Elsevier/Gold Standard, Inc. 2014. Available at http://www.clinicalpharmacology.com. Accessed on January 2, 2015.

http://www.clinicalpharmacology.com/



16. Micromedex [online database]. Available at

www.micromedexsolutions.com. Accessed on January 2, 2015.

17. 2014 ICD-9-CM Diagnosis Codes, Volume 1. 2014. Available at http://www.icd9data.com/. Accessed on January 2, 2015.

18. 2014 ICD-10-CM Diagnosis Codes, Volume 1. 2014. Available at http://www.icd10data.com/. Accessed on January 2, 2015.

19. American Psychiatric Association (APA). Practice guideline for the treatment of patients with panic disorder. 2nd ed. Washington DC: American Psychiatric Association (APS); 2009 Jan. 90 p. Available at www.psychiatryonline.org. Accessed January 2, 2015.

20. Connolly SD, Bernstein GA, et al. Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders. J Am Acad Child Adolesc Psychiatry 2007;46(2):267-283. Available at www.aacap.org. Accessed January 2, 2015.

21. Bandelow B, Sher L, Bunevicius R, et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care. Int J Psych Clin Pract 2012;16:77-84.

22. American Society of Addiction Medicine (ASAM). Public Policy Statement on Measures to Counteract Prescription Drug Diversion, Misuse and Addiction. Adopted January 2012. Available at www.asam.org. Accessed January 2, 2015.

http://www.micromedexsolutions.com/

http://www.icd9data.com/

http://www.icd10data.com/

http://www.psychiatryonline.org/

http://www.aacap.org/

http://www.asam.org/



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

05/08/2012 Added new sections to specify the drugs requiring prior

authorization for each drug subclass

Revised and consolidated criteria logic and logic diagrams for each

drug subclass

Removed Mephobarbital & Midazolam drug subclass from clinical

edit criteria

Removed approval outcome from step 2 in all criteria logic and

logic diagrams

04/03/2015 Updated to include ICD-10s

05/14/2015 Updated alprazolam clinical edit logic, logic diagram and

supporting tables as approved by the DUR Board at the January

2015 DUR Board meeting.

anxiolytics and sedatives/hypnotics (ashs)...anxiolytics – alprazolam drugs requiring prior...

Documents