Does E88.40 require prior authorization?

No, E88.40 does not require prior authorization (high confidence). Covered without prior authorization.

`E88.40`, Mitochondrial metabolism disorder, unspecified

ICD-10-CM

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation of treatment-resistant epilepsy: prior failure of anti-epileptic drugs (Neal et al. trial required failure of at least 2 AEDs) and seizure frequency records (e.g., seizure calendar) as used in multiple cited studies (Weber et al., 2009; Neal et al., 2008).
Seizure outcome documentation: seizure frequency logs/calendars and follow-up seizure outcome assessments (eg, ≥50% seizure reduction or seizure freedom at defined follow-ups) as used in trials cited.
Monitoring during KD and initiation: urine ketone monitoring and serum ketone levels (Cervenka et al., 2017: 'significant urine and serum ketone body production as a biomarker of feasibility'); daily urine ketones during initiation (studies cited); serum bicarbonate monitoring (association with topiramate use noted); blood glucose and metabolic monitoring (eg, HbA1c, insulin, lipid profile) as reported in multiple studies.

Covered ICD-10 diagnosis codes if selection criteria are met: E74.4 (disorders of pyruvate metabolism and gluconeogenesis).
Covered ICD-10 diagnosis codes if selection criteria are met: E88.09 (glucose transporter protein type 1 deficiency).
Covered ICD-10 diagnosis codes if selection criteria are met: Epilepsy and recurrent seizures, without status epilepticus (e.g., G40.009, G40.019, G40.109, G40.119, G40.209, G40.219, G40.309, G40.319, G40.A09, G40.A19, G40.B09, G40.B19, G40.409, G40.419, G40.509, G40.802, G40.804, G40.822, G40.824, G40.909, G40.919).
Covered ICD-10 diagnosis codes if selection criteria are met: Lennox-Gastaut syndrome (G40.811 - G40.814).
The ketogenic diet... has been used for the treatment of uncontrolled seizures.
The ketogenic diet may be considered as an adjunctive treatment in children with drug-resistant epilepsy. (NICE, 2004)

AMBETTER-CG-Metab-Endo-Mito-DO-2025.1, Concert Genetic Testing: Metabolic, Endocrine, and Mitochondrial Disorders

AETNA-CPB-0202, Magnetic Resonance Spectroscopy (MRS)

AETNA-CPB-0226, Hospitalization for the Initiation of Ketogenic Diet

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