Lennox Gastaut Syndrome (LGS):
Age Requirement: >= 6
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year

Migraine:
Age Requirement: >= 12
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Migraine Frequency: N/A
Is supporting documentation required for initial approval: No
Is supporting documentation required for re-approval: No
Policy Contains Verbiage for Botulinum Interchangeability: No
Diagnosis of Chronic Migraine Required: No
Required Decrease in Duration of Chronic Migraine for Reauthorization: N/A
Provider Responsibility Language Referenced in Policy: No
Dose Conversion Language Included in Policy: No
Reauthorization Criteria Includes 50% Reduction Language: No
Reauthorization Criteria Includes 7 Day100 Hour Reduction Language: No
Retreatment Language Included in Policy: N/A
Policy Contains ICHD2 or ICHD3 Language: No ICHD2 or ICHD3 criteria exist

Neurology: Epilepsy:
Age Requirement: >= 6
Duration: 1 plan year
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Diagnosis Type(s): 1 of Partial Seizures;Primary Generalized Tonic-Clonic Seizures;Seizures Associated with Lennox-Gastaut Syndrome (LGS)
Used as Adjunctive Treatment: No
Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: N/A
Documented history of persisting seizures after titration to highest tolerated dose of each AED.: No
Lack of compliance as a reason for treatment failure has been ruled out: No
Documentation of treatment failure due to intolerable side effects.: No
Positive Response to Therapy Required for Reauth: Yes
Treatment for Age 17 years or older: No
Treatment for Age 1-16 years old: Yes
History of >= to 30 day trial of other AED required: No
Reapproval based on response: Yes