- Prior Authorization Required
- Neutropenia:
Duration: 12 Month(s)
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
Supporting Documentation Requirements: Medical Tests
Risk Factor for Developing Febrile Neutropenia (FN): 1 of Age greater than 65 years;Bone marrow involvement;Extensive prior chemotherapy/radiation therapy;Liver dysfunction;Open wounds;Poor renal function;Pre-existing neutropenia;Recent surgery
Documented Diagnosis: Yes
Criteria includes risk factor for developing FN: Yes
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