Provider Quick Alert

November 1, 2019
Review all  Medical Coverage Policies at QualChoice.com.
New and Amended Medical Policies

P = Payment Change
C = Code Change
V = Verbiage Change

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI135  V
Corneal Remodeling
11/01/19
Updated language for clarity.
BI152   V
Strabismus Surgery
11/01/19
Expanded indication with distinction of cosmetic surgery for small-angle strabismus.
BI171   C
Rituxan
11/01/19
Adjusted code range for covered Dx.
BI216   V
Bone Mineral Density Studies
11/01/19
Further clarified preventive vs. medical coverage.
BI291   V
Peripheral Atherectomy
11/01/19
Clarified criteria for conservative management to qualify for atherectomy.
BI306  V
Obstructive Sleep Apnea
11/01/19
INSPIRE already considered E/I; added relevant codes for clarity.
BI356  V
Jakafi
11/01/19
Added indication.
BI363   V
Balloon Sinuplasty
11/01/19
Clarified language/codes.
BI366  V
Breast Reconstruction
11/01/19
Added instruction details for prosthesis/bra codes.
BI482  V
Hepatitis C Treatment with Direct Acting Antivirals (DAA)
11/01/19
Added indication for post-transplant HCV treatment.
BI496   V
PCSK9 Inhibitors
11/01/19
Eliminated no-smoking requirement, clarified criteria for peripheral arteria disease.
BI483  V
Cosentyx
12/31/19
Retired policy.
Comi ng Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI144  V
Orencia 01/01/20 Added Xeljanz/XR and Rinvoq to preferred drugs for RA and added Stelara to preferred drugs for psoriatic arthritis.
BI153   V
Humira 01/01/20
Removed NSAID requirement for PsA.
BI171  V
Rituxan 01/01/20 Updated prerequisite drugs for use of rituximab in RA.
BI258   V
Stelara 01/01/20
Removed NSAID requirement for PsA.
BI285  V
Actemra 01/01/20 Updated criteria for PsA.
BI401   V
Xeljanz 01/01/20
Updated criteria for RA (removed requirement for TNF inhibitor first); psoriatic arthritis (removed NSAID requirement and added Stelara to preferred agent); and ulcerative colitis (requires trial of BOTH preferred biologics - Humira and Simponi).
BI478  V
Entyvio 01/01/20 Updated prerequisite drugs for both UC and Crohn's Disease.
BI522   V
Taltz 01/01/20
Updated prerequisite drugs for psoriatic arthritis and added criteria for coverage for ankylosing spondylitis.
BI564  V
Kevzara 01/01/20 Updated prerequisite products to include Xeljanz/XR and Rinvoq along with trial of both Actemra and Orencia.
BI568   V
IL-23 Antagonists 01/01/20
Updated prerequisite drugs for Ilumya.
BI599  V
Olumiant 01/01/20 Updated prerequisite drugs to include Xeljanz/XR and Rinvoq and trial of both Actemra and Orencia.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed
Predetermination Request Form for each patient to 844.501.2830.
1910 MK 006