Does C9254 require prior authorization?

No, C9254 does not require prior authorization (high confidence). Covered without prior authorization.

`C9254`, Injection, lacosamide, 1 mg

HCPCS/CPT

No Prior Auth Required

Covered without prior authorization (high confidence)

Diagnosis documentation: clinical diagnosis of diabetic neuropathy (DN) should be based on at least 2 of the following 5: signs; symptoms; quantitative sensory testing; nerve conduction study; autonomic testing.
Use of validated instruments and examinations: DN4 questionnaire and clinical findings (type of pain, time of occurrence, abnormal sensations) are recommended for diagnosing painful diabetic neuropathy (PDN).
For surgical decompression candidate selection in published series: symptomatic somatosensory neuropathy (pain, burning, tingling, numbness) with pre-operative neurosensory testing (e.g., computer-assisted neurosensory testing or pressure-specified sensory device) confirming elevated nerve threshold levels and axonal degeneration.
For SCS patient selection (from trial eligibility criteria): refractory PDN (symptoms ≥1 year) not responding to conventional therapy; lower limb pain intensity ≥5 on a 10-cm VAS; prior trial of gabapentinoids and at least one other analgesic class; BMI ≤45 kg/m2; HbA1c ≤10%; daily morphine equivalents ≤120 mg; medically appropriate for the procedure.

Diabetes mellitus with neurological complications (ICD-10 codes E08.40-E08.49, E09.40-E09.49, E10.40-E10.49, E11.40-E11.49, E13.40-E13.49) as indications listed in the CPB.
Percutaneous electrical stimulation for the treatment of members with diabetic neuropathy who failed to adequately respond to conventional treatments including anti-convulsants (especially pregabalin), anti-depressants (e.g., amitriptyline, and duloxetine), opioids (e.g., morphine sulphate and tramadol), and other pharmacological agents (e.g., capsaicin and isosorbide dinitrate spray).
Dorsal column stimulation (DCS) for members with diabetic peripheral neuropathy who meet criteria listed in CPB 0194 - Spinal Cord Stimulation.
Surgical decompression may be considered medically necessary for entrapment syndromes even though the person has the concomitant diagnosis of diabetic neuropathy. (footnote)
Amitriptyline, capsaicin, duloxetine, gabapentin, isosorbide dinitrate spray, opioids (e.g., morphine sulfate, and tramadol), valproate, and venlafaxine are probably effective and should be considered for the treatment of painful DN (Level B).
Percutaneous electrical nerve stimulation should be considered for the treatment of painful DN (Level B). The recommended duration for electrical stimulation is 3 to 4 weeks.

AETNA-CPB-0729, Diabetic Neuropathy: Selected Treatments

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