Added disclaimer: All Codes listed in policy are not necessarily covered. See Medical Policy statement for coverage of specific genetic tests. Codes for genetic tests that are NOT listed in any medical policy require pre-authorization.
Added disclaimer: All Codes listed in policy are not necessarily covered. See Medical Policy statement for coverage of specific orthotics. Codes for customized orthotics that are NOT listed in any medical policy require pre-authorization.
Added disclaimer: All Codes listed in policy are not necessarily covered. See Medical Policy statement for coverage of specific braces. Codes for customized braces that are NOT listed in any medical policy require pre-authorization.
Added references highlighting increased potential risks and requirement for informed consent documenting discussion of this data.
BI638 New
Promacta
03/01/20
Used to treat chronic immune thrombocytopenia and severe aplastic anemia. Requires pre-authorization; oral specialty drug covered under pharmacy benefit. Must be obtained through a contracted specialty pharmacy.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.