Provider Quick Alert

December 1, 2017
Visit the Providers section of  QualChoice.com to review all Medical Coverage Policies .
New and Amended Medical Policies

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI020 Chiropractic Care 12/01/17 Added verbiage for Evaluation and Management stating 90 days or 12 treatments. Removed pre-authorization from 98942.
BI090 Speech-Generating Devices 12/01/17 Clarified pre-authorization of device and related services.
BI091 Compression Devices 12/01/17 Clarified excluded codes for circulating hot/cold pads.
BI093 Varicose Vein Treatment 12/01/17 Redefined criteria.
BI240 Supprelin LA 12/01/17 This was an internal inconsistency and an incorrect code; clarified verbiage related with correct code.
BI265 Cardioverter Defibrillators 12/01/17 Clarified pre-authorization requirements.
BI285 Actemra 11/01/17 Changed the prerequisite drugs.
BI534 Back Braces 12/01/17 Added new codes for upper Thoracic Spine. Specified orthotic management/training requirements for pre-authorization.
BI566 Short-Acting Opioid Limits 12/01/17 New policy. Limited amounts of short-acting opioids will be covered. Limits are different for a member who is new to opioid therapy versus one who already uses opioids. No limits for a member with cancer drug scripts in the past 360 days. Coverage is under the pharmacy benefit.
Coming Amendments



Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI038 Genetic Testing 01/01/18
Added coverage for myPath Melanoma test.
BI049 Hearing Aids 01/01/18 Added pre-authorization requirement if hearing aid is needed more than once every 3 years.
BI109 Out-of-Network 01/01/18 Added new permission from AID concerning elective services of out-of-network providers.
BI129 Tumor Markers 01/01/18 Added Z85.3 (personal history of breast cancer) as a covered diagnosis for testing CEA (82738).
BI143 Enbrel 02/01/18 Changed prerequisite on therapy for psoriasis.
BI162 Urinary Incontinence Treatments 01/01/18 Removed Oxytrol from covered products.
BI217 Orthotic Devices and Orthotic Services 02/01/18 Clarified pre-authorization need for orthotic management/training codes.
BI261 Simponi 01/01/18 Added psoriatic arthritis and ankylosing spondylitis as approved indications for Simponi Aria for covered indications.
BI306 Obstructive Sleep Apnea 02/01/18 Added IDTF accreditation requirement language for home sleep testing.
BI342 Nutritional Counseling in Chronic Disease 01/01/18 Will be approved without pre-authorization as long as the appropriate diagnosis is used. Any diagnoses other than what is listed in BI will require pre-authorization. Added cleft palate language.
BI380 Relistor 02/01/18 Updated criteria to require 60-day trial of Movantik.
BI381 Intraoperative Neurophysiologic Monitoring 02/01/18 Documentation requirement clarified for professional component of intraoperative neurophysiologic monitoring. Added out-of-network verbiage.
BI383 Bio-Engineered Soft Tissue Substitutes as Implants 01/01/18 Updated procedure codes for coverage of biologic implants.
BI424 Osphena 01/01/18 Updated to add Intrarosa to coverage policy.
BI439 Transcranial Magnetic Stimulation 01/01/18 Request for TMS requires failure of at least three different drug regimens from two different drug classes. Pre-authorization request requires clinical documentation of drug treatment failures over the previous 18 months of treatment.
BI454 Otezla 01/01/18 Updated perequisite therapy to only one DMARD.
BI464 Urinary Antispasmodics 01/01/18 Removed pre-authorization requirement for tolterodine ER and removed Oxytrol from coverage.
BI482 Hepatitis C 01/01/18 Added coverage/dosing criteria for Mavyret and Vosevi. Deleted coverage of Zepatier.
BI483 Cosentyx 01/01/18 Updated prerequisite therapy for psoriasis, psoriatic arthritis, and ankylosing spondylitis.
BI521 Orfadin 01/01/18 Removed Orfadin from coverage and added NITYR.
BI522 Taltz 02/01/18 Updated prerequisite therapy to include Tremfya and Cosentyx.
BI526 Zurampic 01/01/18 Added Duzallo to policy.
BI532 Hereditary Angioedema Treatment 01/01/18 Added Haegarda to coverage policy.
BI562 Besponsa 01/01/18 New drug used to treat a type of leukemia. Pre-authorization is required. Covered under the medical benefit as a specialty drug.
BI563 IDHIFA 01/01/18 New drug used to treat a type of leukemia. Pre-authorization is required. Covered under the medical benefit as a specialty drug.
BI564 Kevzara 01/01/18 New drug used to treat rheumatoid arthritis. Pre-authorization is required. Covered under the pharmacy benefit as a specialty drug.
BI565 Nerlynx 01/01/18 New drug used to treat breast cancer. Pre-authorization is required. Oral specialty medication covered under the pharmacy benefit. Must be obtained from a contracted specialty pharmacy.
BI567 Syndros 01/01/18 New drug used to treat chemotherapy-induced nausea/vomiting. Oral solution requires pre-authorization. Covered under the pharmacy benefit.
BI568 Tremfya 01/01/18 New drug used to treat moderate to severe psoriasis. Pre-authorization is required. Covered under the pharmacy benefit as a specialty drug.
BI569 Vyxeos 01/01/18 New drug used to treat a type of leukemia. Pre-authorization is required. Covered under the medical benefit as a specialty drug.
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