Provider Quick Alert

May 1, 2018
Review all  Medical Coverage Policies at
New and Amended Medical Policies

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI170 Provigil 01/01/18
Added new criteria.
BI273 Outpatient Therapy for Mental Health and Substance Use Disorders
Mental health and substance use (MH/SU) therapy services must be prescribed by a physician. Psychiatric diagnostic evaluations are covered once per provider, every 12 months. More frequent evaluations per provider within 12 weeks require PA. A provider visit solely with the member's family (except for the legal guardian) is not covered. Marital counselling may be covered by some plans. Requires physician order and documentation of psychological or medical condition of significant severity for initial six visits. Additional visits require pre-authorization.
BI571 Impella 01/01/18
Added guidance on proper coding of disposable supplies.
Varicose Vein Treatment 04/01/18 Clarified: Trial period for conservative management is at least three months before varicose vein ligation, excision, stripping, ablation or sclerotherapy procedures.
BI096 Continuous Glucose Monitoring 04/01/18 Added information/reference showing continuous glucocose monitoring doesn't improve outcomes with Type 2 Diabetes management.
BI147 Rhinoplasty 04/01/18 Added new codes for rep nasal vestibiular stenosis with pre-authorization.
BI198 Diabetic Shoes and Shoe Inserts 04/01/18 Added code K0903.
BI389 Sklice 04/05/18 Retired policy.
BI549 Oral Mesalamine Products 04/05/18 Retired policy.
BI109 OON Referrals 05/01/18 Added emphasis on inability of QualChoice to protect members from balance billing by out-of-network providers if elective services are not pre-approved. Extended wrap network services must also be considered for all OON requests.
BI246 Add-On Codes 05/01/18 Retired policy.
BI265 Cardioverter Defibrillators 05/01/18 Clarified for ICD placement: Patients must be clinically stable and not in shock, from any etiology; should not have any disease, other than cardiac, (such as cancer, renal failure, liver failure) associated with a likelihood of survival less than one year; or uncontrolled supraventricular tachycardia and left ventricular ejection fraction (LVEF) must be measured.
BI363 Balloon Sinuplasty 05/01/18 Added criteria for balloon dilation of the eustachian tube.
BI381 Intraoperative Neurophysiologic Monitoring 05/01/18 Clarified: Remote intraoperative monitoring, as a non-covered service, is not subject to medical necessity determinations.
BI437 High Dose Chemotherapy and Allogeneic Stem Cell Transplant 05/01/18 Added: Donor Lymphocyte Infusion (DLI) is covered for relapse of Acute Lymphoblastic Leukemia (ALL) following allogeneic stem cell transplant.
BI529 Telemedicine Payment Policy Added new codes.
Coming Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
Chiropractic Care
Clarified distinction between rehabilitative chiropractic services and habilitative chiropractic services.
UV Light Therapy
06/01/18 Eliminated pre-authorization requirements for home UVB therapy for psoriasis.
New drug used to treat leukemia. Pre-authorization is required. Covered under the medical benefit as a specialty drug.
Genetic Testing
07/01/18 Updated indications for Prolaris testing per NCCN, which emphasized need for research supporting improved outcomes for therapies involving companion diagnostic testing.
BRCA Testing
Added Germline BRCA1/2 testing: 81479 BRACAnalysis CDx is an FDA-approved companion test for Olaparib (Lynparza). It requires pre-authorization.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.
1803 MK 014