Provider Quick Alert

August 31, 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
BI032
Complications of Non-Covered Care
08/01/18
Retired policy.
BI104 Anesthesia for Dental Procedures 08/01/18
Clarification of types of eligible dental services.
BI169 Macular Degeneration Treatments and Diabetic Macular Edema Treatments
08/01/18
Clarifed difference between low-dose bevacizumab for ocular disease and high-dose bevacizumab for patients with cancer or HHT.
BI299 Avastin 08/01/18
Clarified difference between low-dose bevacizumab for ocular disease and high-dose bevacizumab for patients with cancer or HHT.
Impella 08/01/18 Noted expanded FDA indications for Impella but no change in E/I exclusions.
BI029 UV Light Therapy 09/01/18 UVB device code range updated.
BI040 Eating Disorders 09/01/18
Retired policy.
BI055 Midwife 09/01/18 Configured for different lines of business.
BI062 Preventive Health Benefit 09/01/18
Table Update: Administration of ocular topical medication is part of hospital care; separately reimbursable. Covered as preventive for members up to 90 days of age: V5008, 92551, 92558, 925865-92588, 84437, 84443, 84030, S3850, 83020, 83021. If billed otherwise, covered under medical benefit.
BI091 Compression Devices 09/01/18 Codes updated for ease of searching.
BI162 Urinary Incontinence Treatments 09/01/18
Additional procedure codes updated.
BI182 Intervertebral Disc Prostheses 09/01/18 Clarified that CPT codes 22853, 22854 and 22859 (insertion of intervertebral disc placement) also require pre-authorization.
BI380 Relistor 09/01/18
Updated to note Relistor tablets are not covered.
BI381 Intraoperative Neurophysiologic Monitoring 09/01/18 Updated configuration for additional remote monitoring code and for dual purpose test (limited auditory evoked potentials).
BI382 Bio-Engineered Skin and Soft Tissue Substitutes 09/01/18
Added Grafix for diabetic lower extremity ulcers.
BI332 Monitored Anesthesia
Current
Added clear coding and billing requirements for coverage of monitored anesthesia for providers.
BI534 Back Braces
Current
Updated HCPCS codes for covered back braces in Medical Policy Statement.
Coming Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI079
Botox
10/01/18 Authorizations limited to specific evidence-based protocols (such as PREEMPT protocol for migraines: 155 units given in 31 injections every three months) when criteria are met for botulinum toxin use. 

Must document results of and response to injections at least after every third session.

BI216
Bone Mineral Density Studies
10/01/18
Removed pre-auth requirement above age 30. Appropriate age and diagnosis determine coverage (preventive or medical) and screening interval.
BI306
Obstructive Sleep Apnea
10/01/18
Added greater detail on OSA criteria. When criteria for sleep lab testing is met, split night polysomnography with CPAP titration is approved. If not performed in a single night, a new request must be submitted.
BI402
Cometriq
10/01/18
Clarified which drug is covered for different diagnoses. Labeling is specific. 
BI421
Mekinist
10/01/18
Clarified melanoma criteria, added indications for non-small cell lung cancer and thyroid cancer.
BI422
Tafinlar
10/01/18
Clarified melanoma criteria, added indications for non-small cell lung cancer and thyroid cancer.
BI556
Imfinzi
10/01/18
Added criteria for non-small cell lung cancer.
BI572
Minimally Invasive Glaucoma Surgery (MIGS)
10/01/18
Code and research update.
BI166
Enzyme Replacement Therapy for Lysosomal Storage Disorders
11/01/18
Added Kanuma (J2840) to policy.
BI174
Psychological Testing
11/01/18
Psychological testing is not covered for dementia screening or substance abuse. Usual testing time is 4 to 6 hours (including administration, scoring, and interpretation). Medical necessity should be documented for more than 6 hours of testing. Testing for more than 8 hours is not covered.
BI209
Admission for Eating Disorders
11/01/18
Added criteria for discharge planning and continued inpatient stay. NEW NAME: Management of Eating Disorders
BI313
Dificid
11/01/18
Updated prerequisite criteria to one course of vancomycin.
BI449
Residential Services
11/01/18
Mental health residential care treatment requires evaluation by a psychiatrist and 24-hour-a-day RN nursing onsite. Added criteria for treatment plans and re-admission to substance rehab.
BI089
Dificid
12/01/18
Updated phototherapy and non-biologic DMARD prerequisite therapy criteria.
For urgent questions about QualChoice Medical Coverage Policies, please fax a completed Predetermination Request Form for each patient to 844.501.2830.
1807 MK 003