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Provider Quick Alert

April 1, 2021
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
BI198  V
Diabetic Shoes and Shoe InsertsCurrentRemoved CHI verbiage.
Heart Transplant01/01/21Updated codes. CPT 33995 insertion of LVAD requires pre-authorization and CPT 33997 removal of LVAD is covered without pre-authorization.
BI573  V
Benznidazole-Lampit04/01/21Updated to include coverage criteria for Lampit (nifurtimox).
BI682   New
Alkindi04/01/21Alkindi is used to treat pediatric patients with adrenocortical insufficiency and it is covered under the pharmacy benefit as a specialty drug. Alkindi (hydrocortisone) Sprinkle requires pre-authorization.
BI683   New
Gamifant04/01/21Gamifant is used to treat primary hemophagocytic lymphohistiocytosis (HLH) in adult and pediatric patients with refractory, recurrent, or progressive disease or intolerance with conventional HLH therapy. It is an injectable medication covered under the medical benefit as a specialty drug and requires pre-authorization.
BI684   New
Gavreto04/01/21Gavreto is used to treat patients with metastatic RET fusion-positive non-small cell lung cancer (NSCLC) as detected by an approved test. It is an oral specialty medication covered under the pharmacy benefit and requires pre-authorization.
Coming Amendments

Medical Policy Number
 Medical Policy Name Effective Date of Change Description of Changes
Xolair05/01/21Updated age requirement for chronic idiopathic urticarial to 12 and older.
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.
2103 MK 006