Stelara (ustekinumab)
Please provide the diagnosis this therapy has been prescribed for: _____ _____ ICD–9 Code: _____ If the treatment is for moderate to severe plaque psoriasis, does it affect … Get Document

BCBS 22289 Plaque Psoriasis Request
Chronic Plaque Psoriasis Treatment Request Form Please fax comp let ed form to Accredofor Enbrel Prescriber Name Phone Fax Office Contact Name Mailing Address City State Zip Code Physical Address City State Zip Code DEA Number License Number Diagnosis and Clinical Inform at ion Primary ICD–9 Secondary ICD–9 … Retrieve Full Source

Targeted Laser Phototherapy For Localized
Treatment is for localized, symptomatic psoriasis (ICD–9 code: 696.1) of the hands, feet, on the two sides, from a baseline of 11.8 to 6.3 for laser and from 11.8 to 6.9 for non-targeted NB-UVB. Kollner et al (2005) reported on a patch comparison in 15 patients with stable plaque psoriasis. … Fetch Content

PLEASE NOTE: ALL CHART NOTES/LAB REPORTS IN REFERENCE TO THIS …
Duration of therapy: _____ Diagnosis_____ ICD–9 code Request for Initial Therapy: Chronic plaque psoriasis for > 1 year  YES  NO Current or history of other forms of psoriasis other than chronic plaque psoriasis … Get Doc

BCBS 22289 Plaque Psoriasis Request
Chronic Plaque Psoriasis Treatment Request Form Please fax completed form to DSP Care Management Prescriber Name Phone Fax Office Contact Name Mailing Address City State Zip Code Physical Address City State Zip Code DEA Number License Number NPI Diagnosis and Clinical Information Primary ICD–9 Secondary ICD–9 … Retrieve Here

Medicare Part B Drug Prior Authorization Form Last Reviewed …
 Plaque psoriasis– ICD code: _____  Active Crohn’s Disease– ICD code: _____  Fistulizing Crohn’s Disease– ICD code: _____ … Get Doc

Division Of Medical Services
J3357 H This procedure code is covered for the diagnosis of moderate to severe plaque psoriasis (ICD–9-CM 696.1) in adult patients ages 18 years and older. … View Doc

To:
Select or specify the correct ICD–9 code. This question must be completed. Moderate to severe chronic plaque psoriasis who are candidates for systemic therapy and phototherapy (ICD–9: 696.1) Other (diagnosis and ICD–9 code): 2 Please indicate Amevive®'s dispensing location: pharmacy physician's … Access Content

Drug Utilization Review Board Meeting Meeting Agenda, Open …
Board Discussion/Action H. Amevive ® (alefacept) The current Amevive prior authorization (PA) criteria require the prescriber to manually provide the specific diagnosis of plaque psoriasis since there is no corresponding ICD–9 code. … View Full Source

PRIOR AUTHORIZATION REQUEST FORM Psoriasis Drugs (Amevive …
Diagnosis_____ ICD–9 code _____ Please check one □ Initial Therapy Request □ Chronic plaque psoriasis for > 1 year  YES  NO Current or history of other forms of psoriasis other than chronic plaque psoriasis  YES  NO … Content Retrieval

ICD–9 Codes
ICD–9 Code: Diagnosis : 521.2: Abrasion: 526.4: Abscess, bone: Look up code: Abscess, by location (Procedure code Polyp, maxillary sinus (Procedure code 88304) 526.0: Primordial cyst: 528.9: Pseudoepitheliomatous hyperplasia: 696.1: Psoriasis … Retrieve Doc

Complete Patient And Physician Information (PLEASE PRINT)
Moderate to Severe Chronic Plaque Psoriasis Other: _____ Clinical Dermatology Physician experienced with Stelara therapy (please state): _____ Diagnosis: ICD–9 Code … Get Content Here

CIGNA Tel-Drug Specialty Pharmacy
696.0 (ICD–9) Polyarticular Juvenile Arthritis = 714.30 (ICD–9) Ankylosing Spondylitis = 720.0 (ICD–9) Reactive Arthritis = (ICD–9) Chronic Plaque Psoriasis = 696.1 (ICD–9) Inflammatory Bowel Disease Arthritis = (ICD–9) Other (please specify diagnosis and ICD–9 code): … Get Document

Pharmacy Medical Necessity Guidelines – Effective Date: May …
plaque psoriasis for Amevive (alefacept), Humira (adalimumab), Enbrel (etanercept) and Stelara of more than 100 kg: 90 mg initially and 4 weeks later, followed by 90 mg every 12 weeks. Codes . The following HCPCS/CPT code(s) are: Code … Retrieve Document

PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR …
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD–9-CM) diagnosis code and The ICD–9-CM diagnosis code must correspond with the ICD–9-CM description. Element 13 Check the appropriate box to indicate whether or not the member has a diagnosis of plaque psoriasis. … View Full Source

Psoriasis – Wikipedia, The Free Encyclopedia
Variants include plaque, pustular, guttate and flexural psoriasis. This section describes each type (with ICD-10 code [5] (http://web.ilds.org/icd10_list. php? … Get Content Here

Humira® (adalimumab) Prior Authorization Form
Ankylosing Spondylitis Moderate to Severe Crohn's Disease Moderate to Severe Chronic Plaque Psoriasis Clinical Physician experienced with Humira therapy Other (please state): _____ Diagnosis: ICD–9 Code … Read Content

Impetigo Herpetiformis – Wikipedia, The Free Encyclopedia
Classification and external resources: ICD-10: L ILDS L40.120) ICD–9 Impetigo herpetiformis is a form of severe pustular psoriasis occurring in pregnancy which may occur Small plaque parapsoriasis (Digitate dermatosis, Xanthoerythrodermia perstans) · Large plaque … Read Article

Pruritic Urticarial Papules And Plaques Of Pregnancy – PUPPP
Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy, is the most common rash in pregnant women. Find out more about this condition that affects many pregnant women. … Read Article

Enbrel® (etanercept) – Immune Modulator
Buy and bill Individual's Name: Date of Birth: / / Insurance Identification Number: Individual's Phone Number: Primary Diagnosis: ICD–9 Code(s Page 2 of 2 Other: (3) Chronic to Moderate to Severe Plaque Psoriasis Individual is 18 years of age or older and has chronic moderate to severe plaque … View This Document