- PA_APPLIES
- Lupus Nephritis:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Nephrologist;Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Systemic Lupus Erythematosus (SLE): Age Requirement: >= 5
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Rheumatologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Positive Autoantibody Test Required: Unspecified
SELENA-SLEDAI Score Required: N/A
Reauthorization SELENA-SLEDAI Score Required: N/A
Patient Exclusion Criteria Documented in Policy: 1 of Excluded for patients receiving intravenous cyclophosphamide (Cytoxan);Excluded for patients receiving other biologic therapies;Excluded for patients with HIV, Hepatitis B, or Hepatitis C virus infection
Reauthorization Requirements Documented in Policy: 3 of Documentation of disease stability;Meet Initial Criteria;Shows positive clinical response
Does Policy Include Excluded Indications: Yes
Supporting Documentation Requirements: 1 of Chart Notes;Medical Tests
|