Limited Use Note(s) |
|
PANCRELIPASE EQUIVALENT TO LIPASE & AMYLASE & PROTEASE5000 & 5100 & 320 Units/100mg Gran - 100mg/Scoop
| Reason For Use Code | Clinical Criteria |
|---|---|
| 124 | Replacement therapy for pancreatic insufficiency secondary to pancreatic surgery (resection). |
| LU Authorization Period: Indefinite. | |
| 125 | Replacement therapy for pancreatic insufficiency due to chronic pancreatitis. |
| LU Authorization Period: Indefinite. | |
| 126 | Replacement therapy for pancreatic insufficiency due to carcinoma of the pancreas. |
| LU Authorization Period: Indefinite. | |
| 225 | Replacement therapy for pancreatic insufficiency due to cystic fibrosis. |
| LU Authorization Period: Indefinite. |