Provider Quick Alert

February 1, 2018
Review all  Medical Coverage Policies at QualChoice.com.
New and Amended Medical Policies

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI041 Insulin Pumps 01/01/18
Clarified verbiage to state pre-authorization is not required for supplies for an insulin pump.
BI189 Gastric Pacemaker
02/01/18
Updated to add pre-authorization requirement for use in sacral nerve stimulation for fecal incontinence.
BI198 Diabetic Shoes and Shoe Inserts 01/01/18
Clarified verbiage in public statement.
Women's Preventive Health Benefit - Contraception 01/01/18 Updated to state hysterosalpingography (58340 and 74740) is covered once when performed 90 to 120 days after hysteroscopic tubal obliteration procedure (58565).
BI429 Dexamethasone Intravitreal Implant 01/01/18 Updated background.
Coming Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI169 Macular Degeneration Treatments and Diabetic Macular Edema Treatments 03/01/18
Added indication for Choroidal neovascularization due to progressive/severe myopia (mCNV).
BI291
Peripheral Atherectomy
04/01/18 Added criteria for trial and failure of conservative measures for intermittent claudication.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.
1801 MK 005