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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.39 Clinician-Administered Drugs : 9.2.39.22 Immunosuppressive Drugs

9.2.39.22
Immunosuppressive drugs weaken or modulate the activity of the immune system and are most often used in organ transplantation to prevent rejection or to treat autoimmune diseases such as rheumatoid arthritis.
The following procedure codes are benefits of Texas Medicaid:
 
The following procedure codes may be indicated for, but are not limited to, treatment of the following conditions:
 
Multiple sclerosis (MS):
For treatment of relapsing forms of MS and should be reserved for clients who have had an inadequate response to two or more drugs indicated for the treatment of MS.
Plaque psoriasis:
Treatment of adult clients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy.
Alpha-1 proteinase inhibitor deficiency:
For the treatment of clients who have a deficiency of the alpha-1 proteinase inhibitor enzyme (also known as alpha-1 antitrypsin deficiency) in the treatment of emphysema.
Organ rejection:
For the prophylaxis of acute organ rejection in patients receiving renal trans- plantation when used as part of an immunosuppressive regimen that includes cyclosporine and corticosteroids.
Organ rejection:
For the prophylaxis of organ rejection in adults receiving a kidney transplant, to be used in combination with basiliximab injection, mycophenolate mofetil, and corticosteroids.
Systemic lupus erythematosus (SLE):
For use in clients with moderate to severe SLE when other forms of treatment have failed to control moderate to severe symptoms
Multiple sclerosis (MS):
For the reduction of the frequency of relapses in clients with relapsing remitting MS, including clients who have experienced a first clinical episode and have magnetic resonance imaging (MRI) features consistent with MS.
Renal homotransplantations:
Adjunct for the prevention of rejection in renal homotransplantation.
Rheumatoid arthritis:
Azathioprine is indicated only in adult patients meeting the criteria for classic or definite rheumatoid arthritis as specified by the American Rheumatism Association.
Organ rejection:
For the prophylaxis of acute organ rejection in clients receiving renal trans- plants, to be used as a part of an immunosuppressive regimen that includes cyclosporine and corticosteroids.
Allogeneic transplants:
For prophylaxis of organ rejection in kidney, liver, and heart allogeneic transplants.
Organ rejection prophylaxis:
For the prophylaxis of organ rejection in clients receiving allogeneic liver, kidney, or heart transplants.
 
Note:
Oral, self-administered immunosuppressive drugs may be reimbursed for Medicaid fee-for- service clients through the Medicaid Vendor Drug Program (VDP).
Retrospective review may be performed to ensure documentation supports the medical necessity of the service. Authorization is not required for immunosuppressive drugs.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.