Ampyra (dalfampridine) prior authorization
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Defines UnitedHealthcare prior authorization requirements for Ampyra (dalfampridine) for patients with multiple sclerosis who have difficulty walking; applies to pharmacy benefit management and prescribing providers seeking coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Authorization
Covered when ALL of the following are met:
Authorization issued for 12 months
Reauthorization
Covered when ALL of the following are met:
Authorization issued for 12 months
Coverage is subject to applicable state mandates, any relevant federal regulatory requirements, and the member's specific benefit plan terms. These external requirements may supersede or further restrict coverage under this policy. Additionally, other UnitedHealthcare policies and utilization management programs may apply and affect coverage decisions.
Initial Therapy
Initial therapy
Authorization issued for 12 months
Continuation / Reauthorization Criteria
Reauthorization
Authorization issued for 12 months
Coding and Assessment
| No codes listed |
Provider Actions and Documentation
Prior authorization and reauthorization required
Prior authorization is required. Initial approval is granted only when both (1) a diagnosis of multiple sclerosis and (2) a provider attestation that the patient has difficulty walking (e.g., Timed 25-foot Walk) are present; authorizations are issued for 12 months. Reauthorization requires documentation of a positive clinical response confirming the patient's walking improved with Ampyra therapy and will be issued for 12 months.
Submit supporting clinical documentation
Provider must submit documentation supporting the prior authorization request, including the diagnosis and attestation of walking difficulty; include supporting clinical measures where available.
Required documentation
Document a diagnosis of multiple sclerosis and attest that the patient has difficulty walking (for example, Timed 25-foot Walk). For reauthorization, document a positive clinical response demonstrating improved walking with Ampyra therapy.
- Initial: diagnosis of multiple sclerosis and provider attestation of difficulty walking (e.g., Timed 25-foot Walk).
- Reauthorization: documentation of positive clinical response confirming improved walking with Ampyra.
Basis for denial: missing diagnosis or attestation
Lack of documentation of a diagnosis of multiple sclerosis or lack of provider attestation that the patient has difficulty walking may result in denial of the request.
Background
Ampyra (dalfampridine) is a potassium channel blocker indicated to improve walking in patients with multiple sclerosis. Clinical benefit is demonstrated by increased walking speed; the policy focuses on patients with MS who have measurable walking difficulty (for example, assessed using the Timed 25-foot Walk).
Definitions
Quantity Limits
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