Provider Quick Alert: Medical Policy Updates

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Provider Quick Alert

December 30, 2020

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
BI010 C	Flu Immunization	12/01/20	Removed pre-authorization requirement from 90682 and 90673.
BI566 V	Opioid Therapy for Chronic Pain & Short Acting Opioid Limits	12/01/20	Clarified limits not applied if being used to treat terminal illness or for end-of-life care.
BI165 V	Multiple Sclerosis	01/01/21	Updated coverage to include Kesimpta as non-preferred product.
BI406 V	Xtandi	01/01/21	Updated criteria to include metastatic castration-sensitive prostate cancer (CSPC).
BI495	Aripiprazole	01/01/21	Retired policy.
BI591 V	Dupixent	01/01/21	Updated age for atopic dermatitis to 6 and older and added coverage criteria for chronic rhinosinusitis with nasal polyposis.
BI595 V	Orilissa-Oriahnn	01/01/20	Updated to include coverage criteria for Oriahnn.
BI650 V	Vascepa	01/01/21	Updated to include criteria for Cardiovascular Disease Risk reduction.
BI670 New	Blenrep	01/01/21	Blenrep is used to treat multiple myeloma and it requires pre-authorization. It is a specialty drug covered under the medical benefit.
BI671 New	Breztri Aerosphere	01/01/21	Breztri Aerosphere is used to treat Chronic Obstructive Pulmonary Disease (COPD) and it requires pre-authorization. It is covered under the pharmacy benefit.
BI673 New	Evrysdi	01/01/21	Evrysdi is used to treat spinal muscular atrophy (SMA) in patients 2 months of age or older and requires pre-authorization. It is covered under the pharmacy benefit.
BI674 New	Fintepla	01/01/21	Fintepla is used to treat seizures associated with Dravet syndrome (DS) in patients 2 years of age and older and requires pre-authorization. It is covered under the pharmacy benefit.
BI675 New	Jelmyto	01/01/21	Jelmyto is used to treat urothelial cancer and requires pre-authorization. It is a specialty drug covered under the medical benefit.
BI676 New	Monjuvi	01/01/21	Monjuvi is used to treat a type of lymphoma and it requires pre-authorization. It is a specialty drug covered under the medical benefit.
BI677 New	Mycapssa	01/01/21	Mycapssa is used to treat acromegaly patients who have responded to and tolerated treatment with injectable octreotide or lanreotide and requires pre-authorization. It is an oral specialty drug covered under the pharmacy benefit and must be obtained from a contracted specialty pharmacy.
BI678 New	Onureg	01/01/21	Onureg is used to treat acute myeloid leukemia and requires pre-authorization. It is covered under the pharmacy benefit as a specialty drug and must be obtained through a contracted specialty pharmacy.
BI679 New	Rukobia	01/01/21	Rukobia is used to treat human immunodeficiency virus type 1 in heavily treatment-experienced adults with multidrug-resistant HIV infection who are failing their current antiretroviral regimen and requires pre-authorization. It is covered under the pharmacy benefit.
BI680 New	Upneeq	01/01/21	Upneeq is used to treat acquired blepharoptosis in adults and requires pre-authorization. It is covered under the pharmacy benefit.
BI681 New	Zepzelca	01/01/21	Zepzelca is used to treat lung cancer and requires pre-authorization. It is a specialty medication covered under the medical benefit.

Coming Amendments

Medical Policy Number	Medical Policy Name	Effective Date of Change	Description of Changes
BI184 P	Autism Spectrum Disorder Treatment	03/01/21	Electroconvulsive therapy (90870) is considered E/I for Autism Spectrum Disorder.
BI439 V	Transcranial Magnetic Stimulation	03/01/21	TMS requires failure or intolerance to adequate pharmacotherapy, psychotherapy and documentation by ordering physician for reasons for ECT to not be clinically appropriate for the member.

BI672 New	ECT	03/01/21	Electroconvulsive therapy (ECT—also known as electroshock therapy) involves giving electrical impulses to an anesthetized patient to intentionally induce seizures. This is most commonly used to treat severe and/or treatment resistant depression but may also be used for catatonia or certain acute exacerbations of schizophrenia or mania. More than 20 sessions in a treatment series are rarely medically necessary. It requires pre-authorization to ensure medical necessity.

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.

[email protected] | Provider Relations Representatives

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