Medical Policy Number
|
Medical Policy Name |
Effective Date of Change |
Description of Changes |
BI170 |
Provigil |
01/01/18 |
Added new criteria.
|
BI273 |
Outpatient Therapy for Mental Health and Substance Use Disorders |
01/01/18
|
Mental health and substance use (MH/SU) therapy services must be prescribed by a physician. Psychiatric diagnostic evaluations are covered once per provider, every 12 months. More frequent evaluations per provider within 12 weeks require PA. A provider visit solely with the member's family (except for the legal guardian) is not covered. Marital counselling may be covered by some plans. Requires physician order and documentation of psychological or medical condition of significant severity for initial six visits. Additional visits require pre-authorization.
|
BI571 |
Impella |
01/01/18 |
Added guidance on proper coding of disposable supplies.
|
|
Varicose Vein Treatment |
04/01/18 |
Clarified: Trial period for conservative management is at least three months before varicose vein ligation, excision, stripping, ablation or sclerotherapy procedures. |
BI096 |
Continuous Glucose Monitoring |
04/01/18 |
Added information/reference showing continuous glucocose monitoring doesn't improve outcomes with Type 2 Diabetes management. |
BI147 |
Rhinoplasty |
04/01/18 |
Added new codes for rep nasal vestibiular stenosis with pre-authorization. |
BI198 |
Diabetic Shoes and Shoe Inserts |
04/01/18 |
Added code K0903. |
BI389 |
Sklice |
04/05/18 |
Retired policy. |
BI549 |
Oral Mesalamine Products |
04/05/18 |
Retired policy. |
BI109 |
OON Referrals |
05/01/18 |
Added emphasis on inability of QualChoice to protect members from balance billing by out-of-network providers if elective services are not pre-approved. Extended wrap network services must also be considered for all OON requests. |
BI246 |
Add-On Codes |
05/01/18 |
Retired policy. |
BI265 |
Cardioverter Defibrillators |
05/01/18 |
Clarified for ICD placement: Patients must be clinically stable and not in shock, from any etiology; should not have any disease, other than cardiac, (such as cancer, renal failure, liver failure) associated with a likelihood of survival less than one year; or uncontrolled supraventricular tachycardia and left ventricular ejection fraction (LVEF) must be measured. |
BI363 |
Balloon Sinuplasty |
05/01/18 |
Added criteria for balloon dilation of the eustachian tube. |
BI381 |
Intraoperative Neurophysiologic Monitoring |
05/01/18 |
Clarified: Remote intraoperative monitoring, as a non-covered service, is not subject to medical necessity determinations. |
BI437 |
High Dose Chemotherapy and Allogeneic Stem Cell Transplant |
05/01/18 |
Added: Donor Lymphocyte Infusion (DLI) is covered for relapse of Acute Lymphoblastic Leukemia (ALL) following allogeneic stem cell transplant. |
BI529 |
Telemedicine Payment Policy |
|
Added new codes. |