Provider Quick Alert

November 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
Flu Immunizations
Added codes to allow for types of administration (intranasal and physician).
BI047 Counseling and Risk Factor Reduction 10/01/18
Retired policy.
Preventive Health Benefit
Clarified diagnosis/modifier requirements with screening sigmoidoscopy and colonoscopy.
Low Density Lipoprotein (LDL) Measurement  10/01/18
Retired policy.
Retrospective Episodic Payment 10/01/18 Retired policy.
Outpatient Therapy for Mental Health and Substance Disorders 10/01/18 Background information added to support oversight role of psychiatrists, psychiatric APRNs or (if needed) primary care physicians. Restriction for evaluation per year per provider within 12 months does not apply for POS 21, 31 and 51.
Obstetrical Ultrasound 11/01/18
Clarified language for consistency in Public and Medical statements.
Obstructive Sleep Apnea 11/01/18 OSA criteria described in greater detail. When criteria for sleep lab testing is met, approval will be for polysomnography OR split night polysomnography with CPAP titration. If polysomnography is positive but CPAP titration cannot be performed in a single night, a subsequent request must be submited.
Cognitive Rehabilitation 11/01/18
Added indications and limitations for cognitive rehab therapy. 
Coming Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
Varicose Vein Treatment
Clarified coverage: Single unit for sclerotherapy of single vein per limb per calendar year;  two units for multiple vein scleotherapy per limb per calendar year.
Testosterone Replacement
Testosterone replacement is covered only with diagnosis of hypogonadism (E29, E29.1, E29.8, and E29.9). Limit of 6 provider visits per member per calendar year for evaluation and management of low testosterone. 
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.
1810 MK 005