Outpatient Therapy for Mental Health and Substance Use Disorders
Psychotherapy visits do not require pre-authorization. However, QualChoice may review medical records at any time. Initial therapy started without a physician order, or subsequent therapy performed after initial 15 visits by a practice without an individualized written treatment plan by a psychiatrist, psychiatric APRN or (if neither of these is available) a primary care physician or services not meeting medical necessity criteria as described in the Medical Policy Statement section, will be denied retrospectively.
GeneSight panel or any other pharmacogenomics testing panel for Major Depressive Disorder (CPT 81599, 81479 and 84999) is considered experimental and investigational and therefore is not covered.
Medical Policy Number
Medical Policy Name
Effective Date of Change
Description of Changes
Bariatric Surgery-Unity Health
Implantable Infusion Pump
Request for implantable infusion pumps for chronic intractable (non-cancer related) pain requires that the member is considered an appropriate candidate for long-term opioid use and has failed or is intolerant to all other pharmacologic, non-pharmacologic and behavioral management. (Please see Medical Coverage Policy section for details). Added criteria for renewal of intrathecal infusion requests.
Dexamethasone Intravitreal Implant (Ozurdex)
Air ambulance transport due to diversion status of a facility with appropriate level of care requires submission of contemporaneous documentation verifying diversion status at the time of transport.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.