Narcolepsy Type 1:
Age Requirement: >= 18
Duration: 1 plan year
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: No
Specialist Type(s): 1 of Neurologist;Sleep Disorders Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 1 plan year

Narcolepsy Type 2:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Neurologist;Sleep Disorders Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)

Neurology: Narcolepsy:
Age Requirement: >= 18
Duration: 12 Month(s)
Specialist Required: Yes
Medical Test Required: Yes
Specialist Type(s): 1 of Neurologist;Sleep Disorders Specialist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Number of Episodes of Cataplexy Required in Policy: N/A
Documented Duration of Daily EDS Occurrences: N/A
Policy Criteria Required to Document Patient Multiple Sleep Latency Test (MSLT): 1 of MSLT =< 8 min with evidence of >=2 SOREMPs;MSLT with evidence of 1 SOREMP, 15 min from preceding night polysomnography (PSG)
Other causes of sleepiness have been ruled out.: No
Patient must have CSF hypocretin 1 deficiency: Yes
Patient Does Not Have a Deficiency of Succinic Semialdehyde Dehydrogenase: No
Patient Does Not Have a History of Substance Abuse: No
Patient is Not Using a Sedative Hypnotic: No
Patient Will Not Be Using with Alcohol: No
Documentation Requiring Patient to be Enrolled in REMS Success Program: No
Documentation of prescriber enrollment in REMS program: No
Prescriber Must Check Patient's Drug History on Controlled Substance Database: No
Documented Time Period or Frequency of Time That the Precriber Must Regularly See the Patient: N/A
Diagnosis Type(s): 1 of Excessive daytime sleepiness associated with narcolepsy;Narcolepsy Type 1 (with Cataplexy)
Supporting Documentation Requirements: 2 of Chart Notes;Medication History;Polysomnography
Documented Diagnosis: Yes
Patient has >1 Cataplexy Episodes: No
Documented Daily EDS occurrences >= 3 months: No
MSLT <8min with evidence of 2 SOREMP's: No
MSLT with evidence of >= 1 SOREMP's and SOREMP, 15 min from preceeding night PSG: No
CSF Hypocretin-1 Deficiency: Yes
Prescriber Must See Patient Every 3 Months: No