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SHP_202310038 Rev.08/23 Page 10 of 13 Clinical Criteria Supporting Tables Horizant (gabapentin enacarbil): Step 2 (diagnosis of restless leg syndrome) Required diagnosis: 1 Look back timeframe: 730 days ICD-10 Code Description G2581 RESTLESS LEGS SYNDROME Step 4 (diagnosis of postherpetic neuralgia) Required diagnosis: 1 T42.6X2A is a billable diagnosis code used to specify a medical diagnosis of poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm, initial encounter. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2024 through September 30, 2025. 2025 ICD-10-CM Diagnosis Code Z88.8 Allergy status to other drugs, medicaments and biological substances. ICD-10-CM Code: Z88.8 Allergy to gabapentin; National Drug Codes 50090-0894 Gabapentin View information about the NDC, including active ingredients, administration routes, dosage forms, labeler information, and more! T42.6X2A is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Poisn by oth antieplptc and sed-hypntc drugs, slf-hrm, init; The 2025 edition of ICD-10-CM T42.6X2A became effective on October 1, 2024. Z88.9 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Allergy status to unspecified drug/meds/biol subst The 2025 edition of ICD-10-CM Z88.9 became effective on October 1, 2024. Texas Prior Authorization Program Clinical Criteria Gabapentin . October 30, 2023 Revised January 15, 2025 Copyright © 2025 Health Information Designs, LLC 10 gabapentin (gabapentin visits) for adults (ages $18) (N55,732). FDA-approved uses and off-label psychiatric use indications were identified with ICD-9-CM and ICD-10-CM diagnosis codes. CNS-D drugs examined were opioids, benzodiazepines, sedatives-hypnotics, antide-pressants, antipsychotics, first-generation antihistamines, T43.596D is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Underdosing of oth antipsychotics and neuroleptics, subs The 2025 edition of ICD-10-CM T43.596D became effective on October 1, 2024. T42.6X5A is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Adverse effect of antiepileptic and sed-hypntc drugs, init The 2025 edition of ICD-10-CM T42.6X5A became effective on October 1, 2024. Z79.891 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2025 edition of ICD-10-CM Z79.891 became effective on October 1, 2024. This is the American ICD-10-CM version of Z79.891 - other international versions of ICD-10 Z79.891 may differ. Search for and lookup ICD 10 Codes, CPT Codes, HCPCS Codes, ICD 9 Codes, medical terms, medical newsletters, medicare documents and more. Z79.1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Long term (current) use of non-steroidal non-inflam (NSAID) The 2025 edition of ICD-10-CM Z79.1 became effective on October 1, 2024. T42.75XA is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Adverse effect of unsp antieplptc and sed-hypntc drugs, init The 2025 edition of ICD-10-CM T42.75XA became effective on October 1, 2024. F55.8 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2025 edition of ICD-10-CM F55.8 became effective on October 1, 2024. This is the American ICD-10-CM version of F55.8 - other international versions of ICD-10 F55.8 may differ. Z79.899 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2025 edition of ICD-10-CM Z79.899 became effective on October 1, 2024. This is the American ICD-10-CM version of Z79.899 - other international versions of ICD-10 Z79.899 may differ. ICD-10-CM T42.5X1A is grouped within Diagnostic Related Group(s) (MS-DRG v 42.0): 917 Poisoning and toxic effects of drugs with mcc; 918 Poisoning and toxic effects of drugs without mcc; Convert T42.5X1A to ICD-9-CM. Code History. 2016 (effective 10/1/2015): New code (first year of non-draft ICD-10-CM) 2017 (effective 10/1/2016): No change T42.6X2 is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of poisoning by other antiepileptic and sedative-hypnotic drugs, intentional self-harm. The code is not specific and is NOT valid for the year 2025 for the submission of HIPAA-covered transactions. Gabapentin is FDA approved to treat postherpetic neuralgia in adults. Gabapentin is also FDA approved as adjunctive therapy in the treatment of partial onset seizures, with or without secondary generalization, in adults or pediatric patients three years of age or older with epilepsy. ICD-10. ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.
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