Home Parenteral Nutrition (HPN)

Question / Reply or required information
What condition (either surgical or medical) does the patient have resulting in an impairment of gastrointestinal absorption?
Patient’s weight
Patient’s height
What type of central venous access does the patient have?
Is an infusion pump requested?
Is the infusion continuous?
If the infusion is intermittent, what is the schedule?
What is the duration of therapy?
REAUTHORIZATION: above questions and below
Anticipated completion of therapy?

Pulmonary Arterial Drug Therapy

Question / Reply or required information
What is the patient’s diagnosis?
Does the patient have pulmonary hypertension associated with the scleroderma spectrum of diseases? Specify
What medication is requested?
(See medication specific questions below)
What is the patient’s World Health Organization (WHO) clinical classification (i.e. Group I, Group II, etc)
Is the diagnosis confirmed by right sided cardiac catherization?
Is the patient a candidate for other conventional therapies?
What other conventional therapies have been tried without successful patient response?
What is the specialty of the prescribing physician?
Ambrisentan (Letairis) or Bosentan (Tracleer):
What limitations on physical activity does the patient have? (None, slight, marked or full inability)? Specify
What signs and symptoms does the patient have with physical activity? (Undue shortness of breath, fatigue, chest pain, near syncope, right-sided heart failure)? Specify
Are symptoms present at rest?
Have liver enzymes been completed prior to initiation of treatment with Tracleer?
Epoprostenol (Flolan, Veltri , epoprostenol for injection), Iloprost (Ventavis),
Does the patient have symptoms with less than ordinary activity and they are comfortable only at rest?
Does the patient have symptoms with any activity, even when they are at rest?
Is the patient confined to bed or on complete bed rest?
What other medications is the patient currently taking?
Does the patient have congestive heart failure due to severe left ventricular dysfunction?
Has the patient had an initial dose of Epoprostenol in a controlled setting with an absence of pulmonary edema?
Sildenafil citrate (Revatio Tablets Revatio IV), Tadalafil (Adcirca)
Will use of these medications in treating pulmonary arterial hypertension improve exercise ability and delay clinical deterioration?
Does the patient have slight, mild limitations of activity and they are comfortable with rest or mild exertion?
Does the patient have symptoms with less than ordinary activity and they are comfortable only at rest?
Treprostinil Injection (Remodulin), Treprostinil Inhalation Solution (Tyvaso)
Will use of Treprostinil intreating pulmonary arterial hypertension diminish symptoms associated with exercise?
Does the patient require transition from epoprostenol to reduce the rate of clinical deterioration?
Does the patient have symptoms with less than ordinary activity and they are comfortable only at rest?
Does the patient have symptoms with any activity, even when they are at rest?
Is the patient confined to bed or on complete bed rest?
Does the patient have asthma or chronic obstructive pulmonary disease, if yes, specify
REAUTHORIZATION: See above specific medication and below
Has the patient’s clinical condition shown improvement while on therapy for pulmonary arterial hypertension? If yes, specify

Intrathecal Drug Therapy for Long Term Pain Management

(Baclofen, Bupivacaine hydrochloride, Clonidine, Fentanyl, Hydromorphone hydrochloride)

Question / Reply or required information
What is the patient’s diagnosis for intrathecal pain management?
Has the patient been unable to achieve adequate pain control from either oral or intravenous routes of administration?
What methods have been tried and unsuccessful?
Has the patient been evaluated for other health abnormalities that may contribute to an increased sense of pain?
Has the patient had a trial period of intrathecal drug administration?
If yes, what has been the patient’s response?
What medication(s) will be used for intrathecal pain management?
REAUTHORIZATION—See above questions and below
Does the patient require any change in medication, medication concentration or refill frequency to achieve relief?
Has the use of intrathecal pain management allowed the patient enhanced functional ability, physical and emotional well being and enhanced their quality of life?

Fentanyl

Question / Reply or required information
Has the individual has experienced failure of, or has intolerance or contraindications to, noninvasive methods of pain control, including systemic opioids? / Select from drop down:
Yes
No
Have attempts have been made to eliminate physical and behavioral health abnormalities that may contribute to an exaggerated sensation of pain? / Select from drop down:
Yes
No
Has a preliminary trial of intraspinal opioid drug administration has been undertaken with temporary intrathecal/epidural catheter to substantiate pain relief, side effects and patient acceptance? / Select from drop down:
Yes
No

Immune Globulin Therapy

Question / Reply or required information
Select from the list of diagnosis:
Immunological Diseases
Does the patient have a Primary Immunodeficiency? If yes, specify (CVID, hypogammaglobulinemia, etc.)
What is the patient’s immune globulin G level?
Does the patient have a history of frequent infections?
Does the patient have low antibodies?
If the patient is diagnosed with
If the patient has a diagnosis of Wiskott Aldrich only, what is the immune globulin M level?
Does the patient have a history of frequent infections?
Does the patient have low antibodies?
Does the patient have Bullous Dermatoses? If yes, specify (Bullous pemphigoid, Pemphigus vulgaris, etc.)
Is the patient having signs and symptoms of significant disease?
Has the patient tried and failed conventional therapy or is conventional therapy contraindicated? If so, what therapy?
Hematological/Oncological Diseases
Is the patient of pediatric age with a diagnosis of human immunodeficiency?
Does the patient have acute ITP?
If yes, what is the platelet count?
Is that with bleed?
Is the platelet count prior to surgery?
Does the patient have chronic ITP?
If yes, for how long?
Is the patient over 10 years old?
Does the patient have a contraindication or failure of prior steroid treatment?
Did the patient have a previous splenectomy?
Does the patient have ITP of pregnancy?
Did the patient have a splenectomy?
Did the patient have a previous fetal alloimmune immune thrombocytopenia (FAIT) birth?
What is the platelet count?
Does the baby have a diagnosis of natal alloimmune thrombocytopenia (NAIT)?
Does the patient have Acquired/Secondary Humoral Immunodeficiencies with recurrent infection? If yes, specify (CLL, ALL, AML, etc)
What is the Immune Globulin G level?
Does the patient have a history of frequent infections?
Does the patient have low antibodies?
Is the patient post transplant (BMT or solid organ), GVHD prophylaxis or complications from transplant? if yes, specify
How many days is the patient post transplant?
Does the patient have a CMV or RMV infection? Specify
What is the Immune globulin G level?
Does the patient have Kawaski disease?
Does the patient have Autoimmune Hemolytic Anemia?
If yes, did the patient have a splenectomy?
Does the patient have resistance or contraindication to conventional therapy? If yes, specify
Does the patient have multiple myeloma?
If yes, what is the Immune globulin G level?
Does the patient have a history of frequent infections?
Does the patient have low antibodies?
Neurological Diseases
Does the patient have acute infective Polyneuritis (Guillain-Barre)?
Does the patient have Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)?
If yes, is there motor and sensory dysfunction?
Are 2 or more nerves affected?
Was a nerve biopsy study and CSF study done?
Has the patient tried a course of steroid therapy without improvement?
Is the use of steroids contraindicated for this patient?
Does the patient have Inflammatory and Toxic Neuropathy (multifocal motor neuropathy)?
If yes, describe how the symptoms have progressed?
Does the patient have Myesthenia Gravis?
If yes, is the patient considered to be in an acute crisis, (< than 5 days of treatment) with decompensation?
During the initiation of immunosuppression?
Does the patient have disease progression after trying conventional therapy? If yes, specify therapy tried
Is conventional therapy contra-indicated, if so why?
Does the patient have unimproved Dermatomyositis and Polymyositis?
If yes, was it confirmed by muscle biopsy?
Has the physician documented the patient is unimproved?
Did the patient have a failed course of conventional therapy? If yes, what therapy?
Is conventional therapy contraindicated for this patient?
Does the patient have a diagnosis of Stiff Person Syndrome?
If yes, did the patient have a failed course of conventional therapy? If yes, what therapy?
Is conventional therapy contraindicated for this patient?
Does the patient have Relapsing Remitting Multiple Sclerosis?
If yes, does the patient have failure or contraindication to first line therapy? Specify
Infectious Diseases
What infection is being treated with immune globulin therapy?
If diagnosis not listed, please indicate
What is the route of administration for the immune globulin?
For Medicare Advantage Members: see questions above and below
For patients who have a diagnosis of one of the Bullous Dermatoses conditions, has biopsy confirmed the diagnosis? If yes, of which condition?
Has the patient tried and failed conventional therapy?
If so, what therapy?
Is conventional therapy contraindicated?
Does the patient have a rapidly progressing disease in which a clinical response could not be affected quickly enough by using conventional agents?
If yes, what conventional treatment(s) is prescribed along with IVIG?

Alpha 1 Proteinase Inhibitors

Question / Reply or required information
Does the patient have congenital alpha 1-antitrypsin deficiency with evidence of panacinar emphysema? / Select from drop down:
Yes
No
Does the patient have Alpha 1-antitrypsin deficiency with PiZZ, PiZ (null) or Pi (null) Phenotypes? / Select from drop down:
Yes
No
Does the patient smoke? / Select from drop down:
Yes
No

HYDROXYPROGESTERONE CAPROATE

Question / Reply or required information
Does the patient have a history of singleton spontaneous preterm birth? / Select from drop down:
Yes
No
Does the patient have a current or history of thrombosis or thromboembolic disorders? / Select from drop down:
Yes
No
Does the patient have known or suspected breast cancer, other hormone-sensitive cancer, or history of these conditions? / Select from drop down:
Yes
No
Does the patient have an undiagnosed abnormal vaginal bleeding unrelated to pregnancy? / Select from drop down:
Yes
No
Does the patient have cholestatic jaundice of pregnancy? / Select from drop down:
Yes
No
Does the patient have liver tumors, benign or malignant, or active liver disease? / Select from drop down:
Yes
No
Does the patient have uncontrolled hypertension? / Select from drop down:
Yes
No
Has the patient had preterm labor in the current pregnancy? / Select from drop down:
Yes
No
What is the patient’s current gestation?
How often is the patient to receive the medication?

Lidocaine

Question / Reply or required information
What reason does the patient require IV Lidocaine?

Ondansetron HCL IV

Question / Reply or required information
Is this prescribed for nausea and vomiting? / Select from drop down:
Yes
No
Is this prescribed for breakthrough treatment for chemotherapy induced nausea and vomiting? / Select from drop down:
Yes
No
Is this prescribed for prevention of nausea and vomiting associated with radiation treatment ? / Select from drop down:
Yes
No
Is this prescribed for prevention of postoperative nausea and vomiting ? / Select from drop down:
Yes
No
Is this prescribed for hyperemesis gravidarum? / Select from drop down:
Yes
No
If this is for hyperemesis gravidarum has the patient tried and failed conservative treatment such as dietary changes, ginger, multi-vitamin, vitamin B6 ? / Select from drop down:
Yes
No
Have oral, sublingual, or rectal antiemetics failed or are they contraindicated? / Select from drop down:
Yes
No
Has the patient had oral, sublingual, or rectal Dimenhydrinate (Dramamine), Ondansetron (Zofran), Promethazine (Phenergan)l, or Trimethobenzamide (Tigan)? / Select from drop down:
Yes
No
Please list which Oral, sublingual, or rectal antiemetics the patient has tried from the list above.
Have injectable/intravenous antiemetics failed or are they contraindicated?
Has the patient had injectable/intravenous Dimenhydrinate (Dramamine) or Promethazine (Phenergan)? / Select from drop down:
Yes
No

Vitamin B 12

Question / Reply or required information
Does the patient have anemia associated with vitamin B-12 deficiency, as evidenced by macrocytosis, low serum B-12, or abnormal Schilling test? / Select from drop down:
Yes
No
Does the patient have anemia resulting from prior gastrectomy? / Select from drop down:
Yes
No
Does the patient have fish tapeworm anemia? / Select from drop down:
Yes
No
Does the patient have Macrocytic megaloblastic anemia resulting from gastrointestinal disorders? / Select from drop down:
Yes
No
Does the patient have pernicious anemia? / Select from drop down:
Yes
No
Does the patient have neuropathy secondary to vitamin B-12 deficiency? / Select from drop down:
Yes
No
Is the patient in acute phase exacerbation due to malnutrition or alcoholism? / Select from drop down:
Yes
No
Does the patient have combined system degeneration (lateral sclerosis)? / Select from drop down:
Yes
No
Does the patient have dementia associated with vitamin B-12 deficiency? / Select from drop down:
Yes
No
Is this being administered as an adjunct to Alimta®? / Select from drop down:
Yes
No
Is this being administered as an adjunct to Folotyn™? / Select from drop down:
Yes
No

Palonosetron hydrochloride (Aloxi®)

Question / Reply or required information
Is the patient 18 years of age or older? / Select from drop down:
Yes
No
Is the patient being treated with moderately emetogenic cancer chemotherapy? / Select from drop down:
Yes
No
Has ondansetron (Zofran®), or granisetron (Kytril®) failed?
NOTE: Failure ondansetron or granisetron is defined as 2 or more documented episodes of vomiting attributed to the current chemotherapy treatment. / Select from drop down:
Yes
No
What dosage is being prescribed?
Is the patient being treated with highly emetogenic cancer chemotherapy? / Select from drop down:
Yes
No
Is this being used for break through emesis? / Select from drop down:
Yes
No

Granisetron HCl

Question / Reply or required information
Is this being requested for breakthrough treatment for chemotherapy-induced nausea and vomiting? / Select from drop down:
Yes
No
Is this being requested for postanesthetic shivering? / Select from drop down:
Yes
No
Is this being requested for prevention of chemotherapy-induced nausea and vomiting? / Select from drop down:
Yes
No
Is this being requested for prevention of nausea and vomiting associated with radiation treatment? / Select from drop down:
Yes
No
Is this being requested for prevention of postoperative nausea and vomiting? / Select from drop down:
Yes
No
What dosage is being prescribed?

Anti-infective

Question / Reply or required information
What condition is this medication prescribed for?

Albumin

Question / Reply or required information
What diagnosis is the medication being requested for?
What dosage was ordered?

Biological response modifiers: Erythropoiesis Stimulating Agents

Question / Reply or required information
For reason is this medication being prescribed?
What symptoms is the patient experiencing?
What was the patient’s most recent Hematocrit?
What was the patient’s most recent Hemaglobin?
What dosage is being ordered?
Is the patient on dialysis? / Select from drop down:
Yes
No
Is this for anemia related to concomitant chemotherapy for non-myeloid malignancy ? / Select from drop down:
Yes
No
If the answer above is yes, is the patient enrolled in ESA APRISE oncology program? / Select from drop down:
Yes
No
Is this for starting or maintenance ESA therapy? / Select from drop down:
Yes
No
Is this for anemia related to Zidovudine AZT therapy?
If yes have other causes of anemia been ruled out such as iron deficiency or blood loss? / Select from drop down:
Yes
No
Does the patient have HIV? / Select from drop down:
Yes
No
What dosage of Zidovudine AZT is the patient taking?
Is this being requested for anemia due to premature birth? / Select from drop down:
Yes
No
Have other causes for anemia been ruled out?
Is this being requested for anemia related to myelodysplastic syndrome? / Select from drop down:
Yes
No
Has the diagnosis of Myelodysplastic Syndrome been confirmed by bone marrow biopsy or aspiration? / Select from drop down:
Yes
No
Does the patient exhibits variable clinical features depending on the MDS classification and degree of disordered hematopoiesis with anemia such as fatigue, pallor, infection and bleeding or bruising? / Select from drop down:
Yes
No
If this is a request for anemia related to Rheumatoid Arthritis has the patient been diagnosed with RA according to the AmericanCollege of Rheumatology criteria? / Select from drop down:
Yes
No
If the request is for anemia associated with the management of Hepatitis C is the patient being treated with the combination of Ribavirin and Interferon alfa or Ribavirin and Peg Interferon Alfa? / Select from drop down:
Yes
No
Is this being requested for reduction of Allogenic blood transfusions in surgery patients? / Select from drop down:
Yes
No
Is the patient scheduled for major elective non cardiac, non-vascular surgery and expected to require 2 or more units of blood and is unable or unwilling to participate in autologous blood donation? / Select from drop down:
Yes
No
If this is being requested for reduction of Allogenic blood transfusions in a surgery patient is the anemia related to a chronic disease? / Select from drop down:
Yes
No
Are iron supplements going to be given for the duration of therapy? / Select from drop down:
Yes
No

Biological response modifiers: Interferon