Medical Policy Updates - October 2018

Provider Quick Alert

October 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
BI010	Flu Immunizations	09/01/18	Updated to reflect that Intranasal flu vaccines now covered per CDC/ACIP recommendations.
BI024	Medical Necessity Determination	09/01/18	Added language clarifying that placebo treatments are not considered medically necessary.
BI048	Provider Backup Coverage	09/01/18	Retired policy.
BI080	Mandated Care	09/01/18	Retired policy.
BI082	Fitness Centers	09/01/18	Retired policy.
BI200	Irinotecan	09/01/18	Retired policy.
BI246	Add-On Codes	09/01/18	Retired policy.
BI260	Consultation Codes	09/01/18	Retired policy.
BI322	Applied Behavior Analysis	10/01/18	Clarification of non-covered group/family treatments.
BI584	Strensiq	10/01/18	New drug used to treat hypophosphatasia that starts early in life.

Coming Amendments

Medical Policy Number	Medical Policy Name	Effective Date of Change	Description of Changes
BI156	ADHD	11/01/18	Listed Experimental and Investigational tests and services.
BI485	Lenvima	11/01/18	Added hepatocellular cancer and advanced renal cell cancer as covered diagnoses.
BI524	Venclexta	11/01/18	Updated language regarding 17p deletion and added mantle cell lymphoma as covered diagnosis.
BI553	Knee Braces	11/01/18	Codes updated.
BI582	Crystiva	11/01/18	New drug used to treat a rare form of hypophosphatemia.
BI585	Aimovig	11/01/18	New drug used for the prevention of migraine headaches and is covered under the pharmacy benefit.
BI586	Aliqopa	11/01/18	New drug used to treat relapsed follicular lymphoma.
BI587	Palynziq	11/01/18	New drug used to treat phenylketonuria (PKU). Palynziq is an injectable specialty medication and must be obtained through a network specialty pharmacy.
BI588	Tavalisse	11/01/18	New drug used to treat thrombocytopenia in adults with chronic immune thrombocytopenia (ITP).
BI589	Yonsa	11/01/18	New drug used to treat metastatic prostate cancer in combination with methylprednisolone. Yonsa is a specialty drug and must be obtained through a contracted specialty pharmacy.
BI305	Testosterone Replacement	12/01/18	Testosterone testing must be performed at an independent lab with recording of time of day and fasting status. Testosterone replacement is not indicated for decreased sperm counts. Members with complex or multiple endocrine diagnosis require management by endocrinologist. Added criteria for change in dose and frequency of therapy, frequency of monitoring and target serum levels. Combination of testosterone replacement with aromatase inhibitor therapy is not covered.
BI448	Preventive Care Medications	12/01/18	Updated to remove Vitamin D supplementation based on USPSTF recommendation change to Grade D.
BI496	PCSK Inhibitors	12/01/18	Updated criteria to more clearly define high-potency statin requirement and eliminate use of ezetimibe.
BI182	Intervertebral Disc Prostheses	12/01/18	Specified additional FDA-approved intervertebral prostheses, added contraindications and non-smoking requirement to optimize clinical outcomes.
BI583	Long-Acting Opioids	01/01/19	Long-Acting Opioids (LAOs) require prior authorization. If approved, the initial authorization is for 2 months.

For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.

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