Dalfampridine ER is considered medically necessary for patients when all of the
following criteria are met. Initial approval, if granted, will be for 2 months.
diagnosis of multiple sclerosis (G35).
ambulatory and able to complete the 25-foot walk test within 8-45 seconds.
does not have a history of seizures. (no dx of G40.00-G40.919, Z86.69)
normal renal function (ClCr > 50ml/min).
Continuation of therapy requests will be approved for 6 months. Patient must
demonstrate a 20% improvement from baseline in timed walking speed (25-foot walk