Provider Quick Alert

February 28, 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
BI306  V
Obstructive Sleep Apnea
03/01/20
Inspire may be covered in certain circumstances with pre-authorization. Modified BMI criteria and defined PAP intolerance/failure.
BI641   New
Ketamine
03/01/20
Anesthetic agent used in anesthesia, pain management and psychiatry. Has been shown to reduce suicidal thoughts and provide rapid relief from depression.
Comi ng Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI158
Bariatric Surgery 04/01/20 Retired policy.
BI465
Bariatric Surgery - AHEC
04/01/20
Retired policy.
BI394   C
Lumbar Spinal Fusion 05/01/20 Spinal injections performed by neurosurgeons and orthopedic surgeons do not require prior authorization. Medical necessity criteria added for lumbar and thoracic
surgeries. Defined conservative management and criteria for waiver of conservative management. Any disagreement with official reports of advanced imaging studies (CT, MRI
and myelograms) require
documentation by the surgeon in the medical records. Updated CPT code listing to include parent codes.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed
Predetermination Request Form for each patient to 844.501.2830.
2002 MK 003