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.
Updated with specific criteria for coverage of Emgality for episodic cluster headaches.
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.