Provider Quick Alert

December 31, 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
BI038  V
Genetic Testing
12/01/19
Added disclaimer: All Codes listed in policy are not necessarily covered. See Medical Policy statement for coverage of specific genetic tests. Codes for genetic tests that are NOT listed in any medical policy require pre-authorization.
BI217   V
Orthotic Devices and Orthotic Services
12/01/19
Added disclaimer: All Codes listed in policy are not necessarily covered. See Medical Policy statement for coverage of specific orthotics. Codes for customized orthotics that are NOT listed in any medical policy require pre-authorization.
BI534   V
Back Braces
12/01/19
Orthotic management and checkout (97760 and 97763) are covered without pre-authorization. 
BI553   V
Knee Braces
12/01/19
Added disclaimer: All Codes listed in policy are not necessarily covered. See Medical Policy statement for coverage of specific braces. Codes for customized braces that are NOT listed in any medical policy require pre-authorization.
BI022   V
Immunization Coverage
01/01/20
Coverage for 90732 (PPSV23) extended to include age 65 or older. Coverage for 90651 updated for ages 27-45.
BI097 V
Eyelid Surgery
01/01/20
Visual field examinations should be performed by an ophthalmologist. Added criteria for canthoplasty, blepharoptosis, and brow ptosis repairs.
BI104  V
Dental Anesthesia
01/01/20
Clarified criteria per statutory language. 
BI127  V
Capsule Endoscopy
01/01/20
Added limited indications for evaluation of colon.
BI639   New
Polivy (polatuzumab vedotin-piiq) 
01/01/20
Used to treat a type of relapsed or refractory lymphoma; requires pre-authorization. Specialty drug covered under medical benefit.
Comi ng Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI571  V
Impella (pVAD) 03/01/20 Added references highlighting increased potential risks and requirement for informed consent documenting discussion of this data.
BI638   New
Promacta 03/01/20 Used to treat chronic immune thrombocytopenia and severe aplastic anemia. Requires pre-authorization; oral specialty drug covered under pharmacy benefit. Must be obtained through a contracted specialty pharmacy.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed
Predetermination Request Form for each patient to 844.501.2830.
1912 Mk 003