Provider Quick Alert

August 1, 2018
Review all  Medical Coverage Policies at QualChoice.com.
New and Amended Medical Policies

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
Darzalex
01/01/17
Update code J9145 to require pre-authorization.

BI129 Tumor Markers 07/01/18
Removed a diagnosis requirement from payment configuration.
BI133 Hematopoietic Colony
07/01/18
Added code for application only.
BI149 Mechanical Stretching Devices 07/01/18
Updated research citations/references.
Outpatient Therapy for Mental Health & Substance Disorders 07/01/18 90846 - 90847  is covered on a limited basis for select plans only.
BI366 Breast Reconstruction 07/01/18 Added codes S8420 - S8428 for gradient pressure aids (sleeves, gloves, gauntlets). These codes are covered for treatment of lymphedema that resulted as a complications of mastectomy for breast cancer.
BI542 Pulmonary Function Testing 08/01/18
Removed pre-authorization requirements for some PFT's (codes 94726-94729).
Coming Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI079
Botox
09/01/18 Updated code 64615 - Injection/chemodenervation of muscles innervated by facial/trigeminal/cervical spinal/accessory nerves for chronic migraine.
BI116
Neuromuscular Electrical Stimulation
09/01/18
Reinstituted pre-authorization requirement.
BI005
Neuropsychological Testing
10/01/18
Usual testing time is four (4) to six (6) hours to perform (including administration, scoring and interpretation). For more than 6 hours of testing, medical necessity is required for the extended testing and should be documented. Extended testing for more than 8 hours is not covered.
BI101
Cartilage Transplants
10/01/18
Added clinical criteria and limitations for Autologous chondrocyte implantation (e.g., Carticel®, MACI®). Each MACI implant may be used for repair of multiple defects. Also, updated references.
BI111
Allergy Testing
10/01/18
Codes 95024 and 95028 have a maximum combined limit of 40 units per 12 months. Any additional units require pre-authorization. Removed pre-authorization requirements for 95017, 95018 and 95027 (Skin serial endpoint titration (SET) for determination of a safe starting dose for testing or immunotherapy) and that they are covered for a cumulative total of 80 units per calendar year. Some types of allergy testing require evaluation by specialists.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.
1807 MK 003