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Provider Quick Alert

November 1, 2021
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
BI062  V
Preventive Health Benefit10/01/22Added additional dyslipidemia screening once between age 9-11, and at 17 and 21-year visits.
BI311  V
Capresla12/01/21Added coverage criteria for non-small cell lung cancer.
BI340  V
Xeloda12/01/21Included coverage criteria for anal carcinoma and neuroendocrine tumor of the pancreas.
BI358  V
Erivedge12/01/21Added coverage criteria for medulloblastoma.
BI384  V
Bosulif12/01/21Added coverage criteria for acute lymphoblastic leukemia and myeloid/lymphoid neoplasms.
BI385  V
Kyprolis12/01/21Added coverage criteria for Waleenstrom's Macroglobulinemia.
BI388  V
Perjeta12/01/21Added coverage criteria for salivary gland tumor and colorectal cancer.
BI391  V
Factor Products for Bleeding Disorders10/01/21Code updates.
BI458  V
Cyramza12/01/21Added coverage for hepatocellular carcinoma.
BI480  V
Opdivo12/01/21Added coverage criteria for malignant pleural mesothelioma, esophageal cancer, gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma.
BI523  V
Tecentriq12/01/21Added coverage criteria for hepatocellular carcinoma and melanoma.
BI555  V
Bavencio12/01/21Added coverage criteria for gestational trophoblastic neoplasia.
BI582  V
Crysvita12/01/21Added coverage criteria for tumor-induced osteomalacia.

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.