Provider Quick Alert

September 2017
New and Amended Medical Policies

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI011 Computer Aided Diagnosis (CAD) Mammography 08/01/17 Breast digital tomosynthesis (3D digital mammogram, codes 77061-77063) is covered for risk plans.
BI062 Preventive Health Benefit 09/01/17 Added ablative codes for screening colonoscopy.
BI089 Remicade 09/01/17 Updated criteria for drugs to treat psoriasis.
BI099 Interferons 09/01/17 Updated criteria on current recommendations/indications.
BI143 Enbrel 09/01/17 Updated criteria for drugs to treat psoriasis.
BI153 Humira 09/01/17 Updated criteria for drugs to treat psoriasis.
BI163 Forteo 09/01/17 Updated policy name & addition of new drug.
BI165 Multiple Sclerosis 09/01/17 Updated to reflect Rituximab & Ocrevus use in treatment of MS.
BI171 Rituxan 09/01/17 Updated to include use of Rituximab in primary progressive MS.
BI238 HPV Testing 09/01/17 Z-codes now pay as preventative.
BI253 Hospital Acquired Conditions 09/01/17 Defined process to identify criteria for claim adjustments.
BI273 Mental Health & Substance Use Disorders 09/01/17 Added codes for acute psychotherapy.
BI306 Obstructive Sleep Apnea 09/01/17 Added references supporting the use of auto-titrating CPAP devices in the home for patients without significant comorbidities.
BI314 Zytiga 09/01/17 Added alternative dosing regimen and supporting reference.
BI366 Breast Reconstruction 09/01/17 Added diagnosis codes to confirm need; pre-authorization is not required.
BI391 Factor Products 09/01/17 Added new code; removed deleted code.
BI454 Otezla 09/01/17 Updated therapy criteria for drugs used to treat psoriasis.
BI483 Cosentyx 09/01/17 Updated therapy criteria for drugs used to treat psoriasis.
BI522 Taltz 09/01/17 Updated therapy criteria for drugs used to treat psoriasis.
BI554 Alunbrig 09/01/17 New drug; used to treat types of lung cancer.
BI555 Bavencio 09/01/17 New drug; used to treat Merkel Cell Carcinoma (MCC) & advanced bladder cancer.
BI556 Imfinzi 09/01/17 New drug; used to treat advanced bladder cancer.
BI557 Rydapt 09/01/17 New drug; used to treat acute myeloid leukemia.
BI558 Zejula 09/01/17 New drug; used to treat recurrent ovarian cancer.
Coming Amendments



Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI473 Bariatric Surgery-CHI 01/01/18 Updated criteria for treatment to once per lifetime.
BI074 Erectile Dysfunction 11/01/17 Added requirement of at least 3 medical therapies tried unsuccessfully before surgical implants.
BI111 Allergy Testing 11/01/17 Skin patch testing first 80 units are covered without pre-authorization. Additional units require pre-authorization.
BI217 Orthotic Devices and Orthotic Services 11/01/17 Refer to BI553 for knee orthotics.
BI553 Knee Braces 11/01/17 New Benefits Interpretation on knee braces. Some codes may not be covered in this BI.
1708 MK 022