Provider Quick Alert

June 1, 2017
New and Amended Medical Policies



Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI111 Allergy Testing 01/01/17 Clarified which codes for respiratory pulmonary function test are allowed without pre-authorization.
BI117 Allergy Immunotherapy 06/01/17 Clarified the use of the administration codes.
BI352 Repair & Replacement of Durable Medical Equipment (DME) 06/01/17 Clarified verbiage to state that requests for DME repair or replacement need to be submitted by ordering provider office along with provider's clinic progress notes.
Coming Amendments



Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI017 Amniocentesis 07/01/17 Clarified requirements for genetic testing pre-authorization requests, including submission must be by the ordering provider within 3 business days of collection of specimen. Clinical text on lab forms will not be accepted.
BI022 Immunization Coverage 07/01/17 Clarified verbiage that 90740 and 90747 - Hepatitis B vaccine (HepB), dialysis, or immunosuppressed patients require pre-authorization.
BI024 Medical Necessity Determination 07/01/17 Updated language to indicate clarification, not a change: Background and references added to support clarification.
BI033 Viscosupplementation 07/01/17 Eliminated coverage for these injectable products because evidence did not support treatment for osteoarthritis.
BI041 Insulin Pumps 07/01/17 Clarified verbiage to state requests come from the ordering provider only, along with provider's clinic progress notes.
BI062 Preventive Health Benefit
 07/01/17 Added reference to BI508 for BRCA testing. Added 81162 BRCA w/full dup/del analysis is covered. 81213 uncommon BRCA dup/del variants (included in 81162) no longer covered.
BI062 Preventive Health Benefit
 08/01/17 HPV test (87623 Low risk types 6/11, 42, 43 and 44) is covered as preventive once every 60 months if billed with certain diagnosis codes. Code 87625 (HPV types 16 and 18 only) is not covered.
BI085 Cranial Remodeling Bands and Helmets
 07/01/17 Removed pre-authorization requirement.
BI091 Compression Devices
 07/01/17 Removed pre-authorization requirements except for calibrated compression devices-with requirement to first try standard (non-calibrated) compression devices.
BI096 Continuous Glucose Monitoring
 07/01/17 Clarified to state requests need to be submitted by ordering provider office only, along with provider's clinic progress notes.
BI132 Bisphosphonates
 07/01/17 Added indication for Osteogenesis Imperfecta.
BI137 Enteral-Parenteral Nutrition Therapy
 07/01/17 Coverage detailed for nutritional products for single gene, inborn errors of metabolism.
BI176 Conscious Sedation
 07/01/17 Added new codes specifying moderate sedation services rendered by someone other than the provider (these are not covered).
BI198 Diabetic Shoes and Shoe Inserts
 07/01/17 Codes updated. Added L3001-L3003, L3010, L3020, and L3031.
BI214 Torisel
 07/01/17 Updated to include covered diagnoses of soft tissue sarcoma - PEComa/Recurrent Angiomyolipoma/Lymphangioleiomyomatosis and Endometrial Carcinoma.
BI267 Deep Brain Stimulation
 07/01/17 Updated to include coverage for medically intractable essential tremor.
BI337 Denosumab
 07/01/17 Updated to include trial/failure or intolerance to at least two (2) bisphosphonates (oral or injectable) for approval of Prolia to treat osteoporosis.
BI342 Nutritional Counseling in Chronic Disease
 07/01/17 Clarified coverage for single gene inborn errors of metabolism.
BI445 Air Ambulance
 07/01/17 Added verbiage stating minimum miles and documentation for air ambulance transportation coverage.
BI454 Otezla
 07/01/17 Added inadequate response to topical corticosteroids (Class 1 or 2) for plaque psoriasis.
BI469 Keytruda
 07/01/17 Updated criteria to include bladder cancer as covered diagnosis.
BI482 Hepatitis C
 07/01/17 Added background, references, discussion of variable natural course of illness and the medical necessity of active surveillance.
BI535 Eucrisa
 07/01/17 Updated criteria.
BI538 Kisqali
 07/01/17 New Policy - requires pre-authorization; used to treat invasive breast cancer; specialty drug covered under the pharmacy benefit.
BI539 Xermelo
 07/01/17 New Policy - requires pre-authorization; used to treat carcinoid syndrome diarrhea; covered under the pharmacy benefit.
1705 MK 023