Provider Quick Alert

January 31, 2020
Review all  Medical Coverage Policies at QualChoice.com.
New and Amended Medical Policies
P = Payment Change
C = Code Change
V = Verbiage Change

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI062  C
Preventive Health Benefit
07/01/19
Added diagnosis codes for coloerectal screening.
BI130   V
Erythropoietic Therapy
01/01/20
Updated policy to include HCPCs for Retacrit (previously covered but codes not listed in policy).
BI133   V
Hematopoietic Colony-Stimulating Factors
01/01/20
Updated policy to include HCPCs for Zarxio and Nivestym (previously covered but codes not listed in policy).
BI272   C
Obstetrical Ultrasound
01/01/20
Updated codes.
BI552   V
Afinitor
01/01/20
Updated policy to indicate brand name Afinitor is not covered. Only the generic equivalent is covered.
BI530  V
Zoladex
01/01/20
Updated verbiage.
BI093  V, P
Varicose Vein Treatment
02/01/20
Any additional single or multiple vein sclerotherapy procedures (beyond the maximum within a calendar year) require a new pre-authorization and a diagnostic study performed and interpreted by an independent radiologist.
BI196  V
Stereotactic Radiosurgery
02/01/20
Updated criteria for stereotactic radiation (SRS and SBRT). Up to 5 sessions are considered medically necessary.
Comi ng Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI089  P
Remicade 04/01/20 Updated to require use of biosimilar product first for new patient starts before Remicade is approved.
BI165  V
Multiple Sclerosis
04/01/20
Updated coverage for Ocrevus for PPMS.
BI299  P
Avastin 04/01/20 Added requirement for new patient starts on high-dose bevacizumab that a biosimilar product must be tried first.
BI336  V
Benlysta
04/01/20
Updated coverage for IV infusion to age 5 or older.
BI464  V
Urinary Antispasmodics
04/01/20
Removed pre-authorization requirement for solifenacin and added to prerequisite drug list.
BI491  V
Orkambi
04/01/20
Updated coverage for age 2 to 5 years with dosing.
BI492  V
Rexulti
04/01/20
Updated criteria for MDD and added criteria for coverage for schizophrenia.
BI506  V
Nucala
04/01/20
Updated to include coverage for age 6 and older, updated criteria for asthma coverage.
BI510  V
Darzalex
04/01/20
Updated for additional coverage criteria for multiple myeloma.
BI516  V
Buprenorphine-Naloxone
04/01/20
Updated policy to indicate Bunavail not covered.
BI521  V
Nitisinone
04/01/20
Updated verbiage to indicate brand name NITYR and brand name Orfadin are not covered. Only the generic equivalent to Orfadin is covered.
BI585  V
Calcitonin Gene Related Peptide (CGRP) Inhibitors
04/01/20
Updated with specific criteria for coverage of Emgality for episodic cluster headaches.
BI640   New
Trastuzumab 04/01/20 Used to treat breast cancer, gastric cancers and endometrial carcinoma. Trastuzumab biosimilar products (Kanjinti, Ogrivi, Herzuma, Ontruzant, and Trazimera) and Herceptin Hylecta are covered without pre-authorization; subject to retrospective review to ensure use complies with the Medical Policy Statement. Herceptin requires pre-authorization. For new patients, a biosimilar product or Herceptin Hylecta must be tried before Herceptin is approved. 
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed
Predetermination Request Form for each patient to 844.501.2830.
2001 MK 007