Provider Quick Alert

August 2017
New and Amended Medical Policies

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI010 Flu Immunizations 07/01/17 Updated language for choice of preservative-free dosage form of flu vaccines.
BI043 Cardiac Rehabilitation 07/01/17 Clarification in medical policy statement and noted in limits.
BI096 Continuous Glucose Monitoring 07/01/17 Added new codes.
BI129 Tumor Markers 07/01/17 Added code for Oncotype Dx.
BI156 Childhood Attention Deficit/Hyperactivity Disorder Treatment (ADHD) 08/01/17 Added guidance on extended release to require pre-authorization.
BI258 Stelara 04/01/17 Updated codes.
BI276 Negative Pressure Wound Therapy 08/01/17 Clarified documentation requirements.
BI351 Hip Resurfacing Arthroplasty 08/01/17 Added new research showing when procedure is clinically appropriate.
BI372 Women's Preventive Health Benefit - Contraception 08/01/17 Updated codes.
BI517 Makena 07/01/17 Updated codes.
BI536 Lartruvo 07/01/17 Updated codes.
BI543 Angiotensin Receptor Blockers (ARBs) 08/01/17 Drugs covered under pharmacy benefit.
BI544 Cycloset 08/01/17 Drug used along with diet and exercise to treat type 2 diabetes. Covered under pharmacy benefit.
BI545 Flector Patches 08/01/17 Drug used to treat acute pain due to minor strains, sprains, and contusions. Covered under pharmacy benefit.
BI546 Ketoconazole Tabs 08/01/17 Drug with usage limited by FDA due to potentially fatal liver injury, risk of drug interactions, and adrenal gland problems. Covered under pharmacy benefit.
BI547 Livalo 08/01/17 Drug for treatment of high cholesterol.
BI548 Kuvan 08/01/17 Drug for treatment of Phenylketonuria (PKU). Covered under pharmacy benefit.
BI549 Oral Mesalamine Products 08/01/17 Drugs Apriso, Asacol HD, Delzicol, and Mesalamine are target drugs in step therapy. Lialda must be tried first before any target drug will be approved.
BI550 Sutent 08/01/17 Drug used to treat a number of different types of cancer. Covered under the pharmacy benefit.
BI551 Triptans 08/01/17 Drug used to treat migraine headaches; it is subject to step therapy. Covered under the pharmacy benefit.
BI552 Afinitor 08/01/17 Drug used to treat a number of different cancers. Covered under the pharmacy benefit.
Coming Amendments



Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI021 Prolonged Medical Services 09/01/17 Updated with AMA coding guideline terminology.
BI111 Allergy Testing 09/01/17 Removed Pulmonary Function Testing verbiage and created new Benefit Interpretation (BI542).
BI125 Excimer Laser Psoriasis 10/01/17 Added additional step requirement.
BI195 Tykerb 10/01/17 Added criteria.
BI217 Orthotic Devices and Orthotic Services 09/01/17 Removed all configuration from policy and created new Benefit Interpretation for Back Brace (BI534).
BI299 Avastin
 09/01/17 Added new indication for use.
BI369 Korlym 10/01/17 Updated criteria for re-authorization.
BI363 Balloon Sinuplasty
 09/01/17 Procedure has efficacy similar to standard surgical approaches - no longer considered experimental/investigational.
BI486 FEHBP Gender Reassignment Surgery 09/01/17 Updated codes.
BI534 Back braces
 09/01/17 Defined what back brace codes are covered. Defined diagnosis for Rib Belt.
BI542 Pulmonary Function Testing (PFT) 09/01/17 Can be performed in a variety of clinical situations. PFTs, such as spirometry, that are routinely used for confirming or monitoring a diagnosis of asthma or COPD do not require pre-authorization.
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