dextromethorphan/quinidine — United Healthcare
pseudobulbar affect (PBA)
Initial criteria
- Diagnosis of pseudobulbar affect
- AND One of the following: amyotrophic lateral sclerosis (ALS) OR Alzheimer's disease OR multiple sclerosis (MS) OR Parkinson's disease OR stroke OR traumatic brain injury
- AND Documented absence of cardiac rhythm disorders
- AND Prescribed by or in consultation with a neurologist
Reauthorization criteria
- Documentation of positive clinical response to therapy
Approval duration
12 months