Limited Use Note(s) |
|
Limited Use Note(s) |
|
| Reason For Use Code | Clinical Criteria |
|---|---|
| For the prevention of Mycobacterium Avium Intracellular (MAI) in: | |
| 103 | Patients with a CD4+ cell count less than 200/mm3 with an AIDS-defining diagnosis; |
| LU Authorization Period: 1 year | |
| 104 | Patients with a CD4+ cell count less than 100/mm3 without an AIDS-defining diagnosis. |
| LU Authorization Period: 1 year |