- Acromegaly:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Neuroendocrine Tumor (NET):
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Oncology: Carcinoid Syndrome:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Requires diagnosis of Carcinoid syndrome with diarrhea: No
Concomitant Therapy Required with Somatostatin Analog Therapy: No
Patient Required to Try Increased Dosage of Sandostatin: No
- ST_APPLIES
- Pemphigus Vulgaris:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
PID: Immune Globulin:
Duration: 1 year(s)
Documented Diagnosis: Yes
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Documented inability to mount an immune response: Yes
Documentation of severe infection despite prophylactic ABX treatment: Yes
Documented Serum IgG Level: Unspecified
IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: > 2
Supporting Documentation Requirements: Medical Tests
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