- Quantity Limit: limit maximum 90 EA PER 30 day(s)
- PA_APPLIES
- Limb Spasticity:
Age Requirement: >= 12
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Neurologist;Orthopedic Specialist;Physiatrist;Physical Medicine & Rehabilitation Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Pediatric Upper Limb Spasticity:
Age Requirement: >= 12
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Neurologist;Orthopedist;Physiatrist;Rehabilitation specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Spasticity: Adult, Spasticity: Lower Limb, Spasticity: Upper Limb:
Age Requirement: >= 12
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Neurologist;Orthopedist;Physical Therapist;Rehabilitation specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- ST_APPLIES
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