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Provider Quick Alert

March 17, 2023
Review all Medical Coverage Policies at
Coming Amendments

P = Payment Change
C = Code Change
V = Verbiage Change

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI036  V
Bendamustine03/01/23Added Vivimusta to coverage criteria; updated all coverage criteria.
BI096  C
Continuous Glucoe Monitoring07/01/23Noted that K0553 and K0554 were deleted as of 12/31/2022.
BI299  C
Bevacizumab03/01/23Updated to include Q5126.
BI334  V
Adcetris05/01/23Updated criteria for classical Hodgkins for adults and added criteria for classical Hodgkins for peds/adolescents. Updated criteria for T-cell lymphoma, Primary Cutaneous CD30+ T-cell Lymphomproliferative Disorder, and Mycosis Fungoides/Sezary Syndrome. Added continuation criteria for all covered diagnoses.
BI556  V
Imfinzi05/01/23Updated criteria for NSCLC, extensive-stage small cell lung cancer, biliary tract cancer, and hepatocellular carcinoma. Added continuation criteria for all coverage criteria.
BI627  V
Libtayo05/01/23Updated CSCC criteria and added criteria for basal cell carcinoma and non-small cell lung cancer (NSCLC).
BI640  V
Trastuzumab05/01/23Updated preferred biosimilars; added criteria for off-label uses colorectal cancer and salivary gland tumor.
BI711  NEW
Amvuttra03/01/23Amvuttra is used in the treatment of the polyneuropathy of hereditary transthyretin-mediated (hATTR) amyloidosis in adults. It is covered under the medical benefit and requires prior authorization.

For questions about QualChoice Medical Coverage Policies, please contact your Provider Relations Representative at 800.235.7111 or 501.228.7111, ext. 7004, Monday through Friday, 8:00 a.m. to 5:00 p.m.