Provider Quick Alert

October 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
BI352  V
Repair & Replacement of Durable Medical Equipment
08/01/19
In general, repair and replacement of DME does not require pre-authorization. Refer to pre-authorization list or specific medical policies at QualChoice.com for items that do require pre-authorization. 
BI418
Lyrica
09/01/19
Retired policy.
BI011   C
Computer Aided Diagnosis
10/01/19
Added Dx codes covered for DBT.
BI036   V
Bendamustine
10/01/19
Added coverage criteria for Non-Hodgkins T-cell lymphoma, Hodgkin's Lymphoma, Multiple Myeloma, and Waldenstrom's Macroglobulinemia.
BI038  C ,  V
Genetic Testing
10/01/19
Code 81490 is E/I based on low Hayes rating.
BI143  V
Enbrel
10/01/19
Updated to include Skyrizi as preferred brand.
BI204  C
Corticosteroid Intravitreal Implants
10/01/19
Added Yutiq and Dextenza coverage criteria.
BI258  C
Stelara
10/01/19
Updated to include J3358.
BI300  V
Xiaflex
10/01/19
Covered with pre-authorization for diagnosis of Peyronie's disease.
BI306  V
Obstructive Sleep Apnea
10/01/19
Pressure (CPAP) or oral appliances are covered when medically necessary and do not require pre-authorization. Repeat sleep study is not required for replacement of CPAP or oral appliance.
BI391  C
Factor Products
10/01/19
Updated Jivi code (J7208).
BI454  V
Otezla
10/01/19
Removed NSAID requirement from PA.
BI483  V
Cosentyx
10/01/19
Updated to include Skyrizi as preferred brand.
BI491  V
Orkambi
10/01/19
Updated to include coverage for ages 2 to 5 with oral granules.
BI522  V
Taltz
10/01/19
Updated to include Skyrizi as preferred brand for psoriasis.
BI523  V
Tecentriq
10/01/19
Updated criteria for urothelial carcinoma and non-small cell lung cancer.
BI556  V
Imfinzi
10/01/19
Updated criteria for NSCLC for disease has not progressed following platinum-based chemo and radiation therapy.
BI568  V
IL-23 Antagonists
10/01/19
Updated prerequisite therapy options for Ilumya to include Skyrizi and two of the first-line agents, one of which must be Tremfya, and requirement to use Cosentyx as second-line.
BI582  C
Crysvita
10/01/19
Added HCPC J0584 to policy.
BI596  C
Poteligeo
10/01/19
Added C9038 to policy.
BI609  C
Lumoxiti
10/01/19
Added C9045 to policy.
BI628  New
Skyrizi
10/01/19
Skyrizi (risankizumab-rzaa) requires pre-authorization; used to treat moderate-to-severe plaque psoriasis. Specialty drug; must be obtained through a contracted specialty pharmacy.
BI629  New
Silenor
10/01/19
Requires pre-authorization; used to treat insomnia; covered under the pharmacy benefit.
Comi ng Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI022   C
Immunization Coverage 01/01/20 Eliminated coverage of Zostavax.
BI517   V
Makena 01/01/20
Clarified that only generic hydroxyprogesterone caproate injection is covered. Brand name Makena (regardless of strength) is not covered.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed
Predetermination Request Form for each patient to 844.501.2830.
1909 MK 018