Provider Quick Alert

November 27, 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
BI152  V
Strabismus Surgery
11/01/19
Added clarification regarding age and small-angle strabismus and cosmetic surgery.
BI345   V
Testing for Drugs of Abuse
11/01/19
Matched Public and Claim Statements to Medical Statement.
BI375   V
ACTH
11/01/19
Updated to include requirement for two peer-reviewed studies published in the past 10 years for conditions.
BI501   V
Alecensa
11/01/19
Updated to include criteria allowing use as first-line therapy in ALK-positive metastatic NSCLC.
BI584   V
Strensiq
11/01/19
Clarified documentation requirements.
BI124  C
Flow Cytometry
12/01/19
Added monocloncal gammopathy D47.2 as a covered diagnosis for flow cytometry testing. 
BI182  V
Invertebral Disc Prosthesis
12/01/19
Updated codes, corrected pathology codes 88264 and 88265 to 22864 and 22865.
BI217   C
Orthotic Devices and Orthotic Services
12/01/19
Orthotic management and checkout (97760 and 97763) are covered without pre-authorization. 
BI306  V,C
Obstructive Sleep Apnea
12/01/19
Clarified non-covered codes for Inspire.
BI394  V
Lumbar Spinal Fusion
12/01/19
Added codes 22552, 22610, 22864 and 22865 to reflect  pre-authorization requirement. 
BI585   V
Calcitonin Gene Related Peptide (CGRP) Inhibitors
12/01/19
Updated with max limits per FDA prescribing guidelines.
Comi ng Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI165  V
Multiple Sclerosis 01/01/20 Updated coverage criteria to include Mavenclad for SPMS.
BI261   V
Simponi 01/01/20
Updated to include prerequisite therapy for ulcerative colitis.
BI450  V
Lung Cancer Screening 01/01/20 Updated code.
BI524   C
Venclexta 01/01/20
Updated to include approval for CLL/SLL as single agent or in combo with rituximab or obinutuzumab.
BI552  V
Afinitor 01/01/20 Updated to include concurrent use with fulvestrant or tamoxifen (in addition to exemestane) for breast cancer.
BI566   V
Short-Acting Opioid Therapy 01/01/20
Added criteria for opioid use for management of chronic pain as already listed in BI583.
BI630   New
Nubeqa 01/01/20
Used to treat non-metastatic castration resistant prostate cancer; requires pre-authorization. Oral specialty drug covered under the pharmacy benefit; must be obtained from a contracted specialty pharmacy.
BI631   New
Piqray 01/01/20 Used to treat advanced breast cancer; requires pre-authorization. Oral specialty medication covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI632   New
Rinvoq 01/01/20
Used to treat rheumatoid arthritis; requires pre-authorization. Specialty drug covered under the pharmacy benefit; must be obtained from a contracted specialty pharmacy.
BI633   New
Sunosi 01/01/20 Used to improve wakefulness in adult patients with excessive daytime sleepiness (EDS) associated with narcolepsy or obstructive sleep apnea.
BI634   New
Turalio 01/01/20
Used to treat tenosynovial giant cell tumor. Oral specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI635   New
Xpovio 01/01/20 Used to treat multiple myeloma. Oral specialty drug covered under the pharmacy benefit; must be obtained through a contracted specialty pharmacy.
BI636   New
Zelnorm 01/01/20
Used to treat women under 65 years of age with irritable bowel syndrome with constipation (IBS-C).
BI637   New
Bariatric Surgery 01/01/20 New policy based on removal of exclusion criteria for large group policies beginning 1/1/2020 as plans begin or renew.  
BI583  V
Long-Acting Opioids 02/01/20 Updated policy title and referenced CDC Guideline for Prescribing Opioids for Chronic Pain. Changed criteria from trial of 2 to 3 pharmacologic agents.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed
Predetermination Request Form for each patient to 844.501.2830.
1911 MK 003