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Provider Quick Alert

October 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
BI426  V
Review of Experimental Surgical Devices10/01/20Added reference to BI024 Medical Necessity Determinations.
BI517  V
Hydroxyprogesterone Caproate10/01/20Clarified that all dosage forms of Makena (hydroxyprogesterone caproate) are covered subject to required pre-authorization.

Coming Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
Zytiga12/01/20Added metastatic castration-sensitive prostate cancer as covered diagnosis.
Entyvio12/01/20Removed step therapy requirement through Humira for ulcerative colitis.
Enteral/Parenteral Nutrition Therapy01/01/21Enteral nutrition is covered based on medical necessity criteria.
Outpatient Therapy for Mental Health & Substance Use Disorders01/01/21Individual psychophysiologic therapy with biofeedback (CPT 90875-90876) are not considered medically necessary and are therefore not covered.  
Cimzia01/01/21Updated prerequisite drug therapy required for RA and PsA to include one (1) DMARD.
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.

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