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Multiple sclerosis and treatments

Patient: 67 year old man with multiple sclerosis on gilenya who developed speech difficulty and imbalance thought to have an MS relapse.

Is Preauth Required? Treatment with Gilenya may be justified for this patient if the individual is between 18 and 45 years of age with disease duration less than 10 years and has a Expanded Disability Status Scale (EDSS) score from 2.0 to 5.5 and has highly active and treatment resistant disease. MRI may be used to support the diagnosis and to monitor disease activity. Additionally, Gilenya may be justified if the individual has recently experienced a clinical relapse or MRI activity. Will the claim be denied? Diagnosing MS relapses can be difficult and is based on clinical judgement as there are no specific clinical or laboratory tests for MS relapse. In this case, imaging of the brain may be helpful to confirm a diagnosis of MS relapse in the patient. However, since the patient is 67 years old, it may be difficult to determine if the symptoms are due to MS relapse or due to age-related changes in the brain. Therefore, the claim may be denied based on the lack of clinical evidence. When is the following treatment medically necessary for the condition specified? Medical treatment is considered medically necessary for this condition because multiple sclerosis is a chronic, disabling autoimmune disease that typically occurs between the ages of 20 and 40, and can cause relapses and disability progression over the course of 30 to 40 years. This 67 year old man's symptoms and signs involving different regions of the central nervous system, such as the optic nerve, brainstem, cerebellum, cerebral hemispheres, and spinal cord, are consistent with a diagnosis of multiple sclerosis, and treatment with Gilenya is an appropriate measure to address the relapse. What are the relevant codes for the treatment? CPT code 81227 CYP2C9 should be used for this treatment and condition.

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