Provider Quick Alert

March 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
BI273   V
Outpatient Therapy for Mental Health and Substance Use Disorders 07/01/18
Psychotherapy visits do not require pre-authorization. However, QualChoice may review medical records at any time. Initial therapy started without a physician order, or subsequent therapy performed after initial 15 visits by a practice without an individualized written treatment plan by a psychiatrist, psychiatric APRN or (if neither of these is available) a primary care physician or services not meeting medical necessity criteria as described in the Medical Policy Statement section, will be denied retrospectively.
BI161   C
Pregnancy Coverage
01/01/19
Codes updated.
BI322   C
Applied Behavior Analysis 01/01/19 New ABA codes with different time increments are replacing older codes.
BI580  C
Emergency Department Services 01/01/19 Additional coverage for vaginitis for children 6 and under, as recommended per Dr. Lu from our Medical Advisory Committee (MAC).
BI368  V
Ampyra 02/01/19 Brand name Ampyra is not covered. It is used to improve walking in patients with multiple sclerosis. Replaced Ampyra with Dalfampridine ER; requires pre-authorization.
BI111  C
Allergy Testing 03/01/19 Code correction/clarification.
BI182  C, V
Invertebral Disc Prosthesis 03/01/19 Specified intervertebral disc placement requires spinal surgery (parent procedure) codes.
BI204   P
Corticosteroid Intravitreal Implants
03/01/19
Established coverage criteria for Retisert and Iluvien. Included criteria for Ozurdex as well, to include all corticosteroid intravitreal implants in same policy.
BI366   C, V
Breast Reconstruction 03/01/19 For members who have had mastectomy for breast cancer, 2 prostheses with mastectomy bras are covered per calendar year.
BI395   V
Clinical Trial Coverage
03/01/19
Added the need to document potential trial risks/benefits/complications and reasonable alternatives via informed consent.
BI469   V
Keytruda 03/01/19
Updated criteria for Merkel cell carcinoma.
BI480   V
Opdivo 03/01/19 Updated criteria for hepatocellular cancer by removing requirement for progression on, or intolerance to, Nexavar per NCCN.
BI512   V
Tagrisso 03/01/19
Updated criteria to include metastatic EGFR (exon 19 deletion or exon 21 (L858R) substitution) mutation-positive NSCLC.
BI581   C
Pharmacogenetics 03/01/19 GeneSight panel or any other pharmacogenomics testing panel for Major Depressive Disorder (CPT 81599, 81479 and 84999) is considered experimental and investigational and therefore is not covered. 
Coming Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI058
Respite Care
04/01/19 Retired policy.
BI219
Bariatric Surgery-Unity Health
04/01/19
Retired policy.
BI320  V
Implantable Infusion Pump 04/01/19 Request for implantable infusion pumps for chronic intractable (non-cancer related) pain requires that the member is considered an appropriate candidate for long-term opioid use and has failed or is intolerant to all other pharmacologic, non-pharmacologic and behavioral management. (Please see Medical Coverage Policy section for details). Added criteria for renewal of intrathecal infusion requests. 
BI335
Krystexxa 04/01/19 Retired policy.
BI429
Dexamethasone Intravitreal Implant (Ozurdex) 04/01/19 Retired policy.
BI445  V
Ambulance Services 04/01/19 Air ambulance transport due to diversion status of a facility with appropriate level of care requires submission of contemporaneous documentation verifying diversion status at the time of transport.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed
Predetermination Request Form for each patient to 844.501.2830.
1902 MK 018