Rule Category: Pharmaceutical

Ref: No: 2011-PR-0029 Version Control: Version No. 2.0 Effective Date: August 2013 Revision Date: August 2014

Neurobion Indications
Adjudication Rule
Table of content
Abstract Scope Adjudication Policy Page 1 Page 2 Page 2 Adjudication examples Page 2 Denial codes Page 2 Appendices Page 2

Abstract
For Members
Neurobion is a complex vitamin supplement containing; Vitamin B1, Vitamin B6, and Vitamin B12. It is indicated, where deficiency of the relevant vitamins exists. Due to its important effect on nerve regeneration it is commonly prescribed for various neurological deficits. Neurobion is covered for all health insurance plans administered by Daman (subject to policy terms and conditions), if medically indicated.

Approved by: Daman Responsible: Medical Strategy & Development Department Related Adjudication Rules: None System Rules: None

For Medical Professionals

Neurobion is covered for all health insurance plans administered by Daman (subject to policy terms and conditions), if medically indicated. Indications of Neurobion are: Mono and polyneuropathies of any origin such as diabetic, alcoholic or toxic neuropathies, Neuritis or Neuralgia (especially cervical syndrome, shoulder- arms syndrome), Sciatica, and Herpes zoster Deficiency of relevant vitamins
Disclaimer
By accessing Daman Adjudication Rules, you acknowledge that you have read and understood the terms of use set out in the disclaimer below: Daman Adjudication Rules are intended to outline the procedures in adjudication as applied by the National Health Insurance Company Daman PJSC (hereinafter Daman). The Daman Adjudication Rules are not intended to be fully comprehensive and are not intended to grant rights or impose obligations on Daman. The Daman Adjudication Rules are not recommendations for treatment and should never be used as treatment guidelines. Daman shall not be liable for any direct, indirect, incidental or consequential damages, costs, losses or liabilities whatsoever arising out of the use of, access to, or inability to use or access the Daman Adjudication Rules or reliance on any information provided on this website. Any information provided herein is general and is not intended to replace or supersede any laws or regulations related to the Adjudication Rules as enforced in the United Arab Emirates or any other written document governing the relationship between Daman and its contracting parties.

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550) Doc Ctrl No.: TEMP/MSD-006 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 1 of 2

Neurobion Indications

Scope
This guideline aims to specify the coverage details of Neurobion for all health insurance plans administered by Daman. Neurobion is a combination of neurotropic vitamins B1, B6, & B12, marketed by Merck. These vitamins in their role as co-enzymes are indispensable factors in the metabolism of the nervous system. Neurobion normalizes the nerve cell metabolism. Neurobion supports the regeneration of nerve fibre and myelin sheath by activation of the metabolism and the natural repair mechanism.

treating physician. Will the drug be covered for this patient? Answer: Yes, The claim will be paid. Example 2 Question: A 47 year old Basic card holder was diagnosed with Alcoholic Polyneuropathy and advised to take Neurobion by his treating physician. Will the drug be covered for this patient? Answer: No, The claim will be rejected as any treatment related to alcoholism is a general exclusion in this plan.

Adjudication Policy
Eligibility / Coverage Criteria
Neurobion is covered for all health insurance plans administered by Daman (subject to policy terms and conditions), if medically indicated. Indications for Neurobion are: Mono and polyneuropathies of any origin such as diabetic, alcoholic or toxic neuropathies, Neuritis or Neuralgia (especially cervical syndrome, shoulder- arms syndrome), Sciatica, and Herpes zoster Deficiency of relevant vitamins

Denial codes
Code Code description
Service is not clinically indicated based on good clinical practice, without additional supporting diagnoses/activities Diagnosis(es) is (are) not covered Service is not clinically indicated based on good clinical practice Service/supply maybe appropriate, but too frequent

MNEC-004

NCOV-001 MNEC-003 MNEC-005

Appendices
Requirements for Coverage
ICD and CPT codes must be coded to the highest level of specificity.

Reference
1. Martindale drug information 2. Neurobion drug leaflet

Non-Coverage
Neurobion, if medically indicated is covered for all health insurance plans administered by Daman (subject to policy terms and conditions).

3. R. Pop-Busui and E. Feldman. (2011). Diabetic neuropathy. Available: https://online.epocrates.com/noFrame/showPag e.do?method=diseases&MonographId=531&Acti veSectionId=42. Last accessed 29th May 2010.

Payment and Coding Rules

Please apply HAAD payment rules and regulation and relevant coding manuals for ICD, CPT, etc.

Revision History
Date Change(s)
V 2: New template

Adjudication Examples
Example 1 Question: A 38 year old Regional card holder was diagnosed with Type II Diabetes Mellitus With Neurological Manifestations and Polyneuropathy in Diabetes and advised to take Neurobion by his

01-07-13

National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550) Doc Ctrl No.: TEMP/MSD-006 Version No.: 1 Revision No.: 0 Date of Issue: 08.05.2013 Page No(s).: 2 of 2