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| Dario Blood Glucose Test Strip (blood sugar diagnostic) |
| Medical Supplies and Durable Medical Equipment : Medical Supplies and Durable Medical Equipment |
- Quantity Limit: limit maximum 360 EA PER 30 day(s)
- CIDP: Immune Globulin:
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Neurologist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year
Progressive or Relapsing Disease Course Required: Yes
Electrodiagnostic Evidence of Demyelination Required: Yes
Supporting Documentation Requirements: 2 of Chart Notes;Medical Tests
Pemphigus Vulgaris:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Dermatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
PID: Immune Globulin:
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): Immunologist
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Documented inability to mount an immune response: Yes
Documentation of severe infection despite prophylactic ABX treatment: Yes
Documented Serum IgG Level: N/A
IgG Subclass Level Referencing Standard Deviation Below Age Adjusted Mean: N/A
- Available through Specialty Pharmacy;
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