New and Amended Medical Policies

Medical Policy Number	Medical Policy Name	Effective Date of Change	Description of Changes
BI011	Computer Aided Detection (CAD) Mammography	01/01/17	Updated codes.
BI038	Genetic Testing	01/01/17	Updated codes; clarified pre-authorization criteria.
BI066	Contact Lenses	01/01/17	Updated codes.
BI093	Varicose Vein Treatment	01/01/17	Updated codes.
BI129	Tumor Markers	01/01/17	Updated codes.
BI176	Conscious Sedation	01/01/17	Updated codes.
BI288	Platelet Rich Plasma	03/01/17	References updated.
BI291	Peripheral Atherectomy	01/01/17	Updated codes.
BI352	Repair & Replacement of Durable Medical Equipment (DME)	04/01/17	Replacement of DME is not covered simply for expiration of warranty or for updating to new DME with new features.

Coming Amendments

Medical Policy Number	Medical Policy Name	Effective Date of Change	Description of Changes
BI022	Immunization Coverage	05/01/17	Updated dosing regimen for HPV to age 9-26 for both male and female.
BI038	Genetic Testing	05/01/17	Updated to change Prolaris from experimental / investigational to requiring pre-authorization.
BI084	Human Growth Hormone	05/01/17	Clarified specialist requirements.
BI089	Remicade (Infliximab)	05/01/17	Updated to clarify pre-authorization requirement.
BI091	Compression Devices	05/01/17	Noted devices are used more frequently following surgery, and patients may take devices home.
BI129	Tumor Markers	05/01/17	Added new code (not covered) with explanation regarding medically necessary testing for elevated PSA.
BI149	Mechanical Stretching Devices for Contractures and Joint Stiffness	05/01/17	Added new codes and noted continuous passive motion as an exclusion.
BI153	Humira (Adalimumab)	05/01/17	Added non-infectious uveitis as covered diagnosis.
BI162	Urinary Incontinence Treatments	06/01/17	Added behavioral modification information and references. Added emphasis on pre-authorization requirements for InterStim Trial.
BI165	Multiple Sclerosis	05/01/17	Updated criteria for non-preferred product Gilenya.
BI200	Camptosar (Irinotecan)	05/01/17	Updated to include approved diagnoses of gastric cancer, non-small cell lung cancer, bone cancer, anaplastic gliomas, pancreatic adenocarcinoma, ovarian cancer and non-pleomorphic rhabdomyosarcoma.
BI205	Fetal Genetic Testing	05/01/17	Updated standard of care to allow routine screening without maternal age restriction or pre-authorization.
BI258	Stelara	05/01/17	Added coverage of Crohn’s disease, subject to noted pre-authorization criteria.
BI306	Obstructive Sleep Apnea	06/01/17	Added pre-authorization requirement for polysomnography in sleep lab to encourage home sleep studies.
BI337	Denosumab	05/01/17	Updated to include Prolia approved for men with osteoporosis and Xgeva approved for hypercalcemia of malignancy refractory to bisphosphonate therapy.
BI382	Bio-engineered Skin and Soft Tissue Substitutes	05/01/17	Added additional bioengineered skin and tissue substitutes for diabetic lower extremity ulcers and for breast reconstruction.
BI469	Keytruda	05/01/17	Updated criteria regarding melanoma and non-small cell lung cancer. Added approved diagnoses of head and neck cancer, colon or rectal cancer, Hodgkin’s lymphoma and Merkel cell carcinoma.
BI480	Opdivo	05/01/17	Updated for approved diagnosis of bladder cancer.
BI534	Back Braces	06/01/17	New policy: in general, back braces are not covered for chronic low back pain. Off-the-shelf orthotics that do not require adjustment by a clinical provider are not covered. Only certain types of braces with specific diagnosis are covered.
BI535	Eucrisa	05/01/17	New policy: used to treat atopic dermatitis. Pharmacy benefit will require pre-authorization.
BI536	Lartruvo	05/01/17	New policy: used to treat soft tissue sarcomas. Pharmacy benefit will require pre-authorization.
BI537	Rubraca	05/01/17	New policy: used to treat ovarian cancer. Pharmacy benefit will require a pre-authorization.

View all QualChoice Medical Policies.

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