Medical Policy Updates

Provider Quick Alert

March 30, 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
BI093	Varicose Vein Treatment	01/01/18	Added new codes for 2018.
BI111	Allergy Testing	01/01/18	Added new code for 2018.
BI138	Services for Disabled Children	04/01/18	Retired policy (combined with Habilitative Services policy BI398).
BI157	Immune Globulin	01/01/18	Added J1555 (Cuvitru) to policy.
BI162	Urinary Incontinence Treatments	01/01/18	Added new code for 2018 (E/I).
BI185	Cochlear Implants	01/01/18	Added new DME codes for 2018.
BI249	Prosthetics	01/01/18	Added new gasket/seal code for 2018.
BI250	Saphris	04/01/18	Oral drug used to treat schizophrenia and some forms of bipolar disorder. Drug has serious side effects and should be prescribed only by a psychiatrist.
BI259	Folotyn	04/01/18	Updated covered diagnoses.
BI333	Photodynamic Therapy for Dermotologic Conditions	01/01/18	Updated codes to reflect revised CPT/HCPCS code 96567.
BI336	Benlysta	04/01/18	Added coverage of Benlysta SQ injection.
BI382	Bio-Engineered Skin and Soft Tissue Substitutes	01/01/18	Added new 2018 codes.
BI391	Factor Products	01/01/18	Added J7211 to policy.
BI394	Lumbar Spine Fusion	01/01/18	Added new CPT code 20939.
BI409	Kadcyla	04/01/18	Added covered diagnosis of non-small cell lung cancer.
BI419	SGLT-2 Inhibitors	01/01/18	Updated to indicate Farxiga is non-formulary and non-covered.
BI420	DPP4 Inhibitors	01/01/18	Updated policy to reflect which DPP4 inhibitors are covered on formulary.
BI423	GLP-1 Agonists	01/01/18	Updated to include listing of non-covered products.
BI431	Psychotherapy Coding	03/15/18	Retired policy.
BI467	Beledaq	04/01/18	Updated covered diagnoses per NCCN Guidelines.
BI469	Keytruda	04/01/18	Updated criteria regarding NSCLC and added additional covered diagnoses (bone cancer, hepatobiliary, pancreatic adenocarcinoma and penile cancer).
BI528	Vyvanse	04/01/18	Added moderate to severe binge-eating disorder to covered indications.
BI542	Pulmonary Function Testing	01/01/18	Added new codes for 2018.
BI543	ARBs	04/01/18	Removed olmesartan (and combination products containing olmesartan) from target drug list and added to pre-requisite list.

Coming Amendments

Medical Policy Number	Medical Policy Name	Effective Date of Change	Description of Changes
BI020	Chiropractic Care	06/01/18	Clarified distinction between rehabilitative chiropractic services and habilitative chiropractic services.
BI029	UV Light Therapy	06/01/18	Emphasized in-home UVB therapy before initiating biologic/immunosuppressive therapy for psoriasis-eliminating homebound requirement and DME cost share.
BI067	Speech Therapy	06/01/18	Clarified that ST is covered only as an individualized 1:1 intervention, not as a group. Also clarified distinction between rehabilitative ST and habilitative ST.
BI089	Remicade	06/01/18	Updated phototherapy requirement.
BI096	Continuous Glucose Monitoring	05/01/18	Transmitters for Continuous Glucose Monitors are limited to two every 12 months. Additional transmitter requests require documentation of transmitter malfunction by the ordering provider. Codes were also updated for 2018.
BI104	Dental Anesthesia	06/01/18	Added new codes for 2018.
BI124	Flow Cytometry	05/01/18	Added covered diagnosis for elevated and decreased white cell counts (D72.820-D72.89 and disorders of white cells (D72.9)).
BI143	Enbrel	06/01/18	Updated phototherapy requirement.
BI153	Humira	06/01/18	Updated phototherapy requirement.
BI258	Stelara	06/01/18	Updated phototherapy requirement.
BI307	Physical and Occupational Therapy	06/01/18	Clarified unlisted therapies/procedures and group therapies are not covered. Also clarified distinction between rehabilitative PT/OT and habilitative PT/OTST.
BI363	Balloon Sinuplasty	05/01/18	Added criteria for balloon dilation of the Eustachian tube.
BI373	Dental Treatment in Accidental Injury	06/01/18	Added new 2018 codes.
BI398	Habilitative Services	06/01/18	Further clarified distinction between habilitative and rehabilitative therapies, which plans cover habilitative services and which policies govern payment limitations on chiropractic, ST and PT/OT service codes. Also combined with policy for services for disabled children to eliminate confusion and duplication. (No CHI/ASO)
BI454	Otezla	06/01/18	Updated phototherapy requirement.
BI483	Cosentyx	06/01/18	Updated phototherapy requirement.
BI522	Taltz	06/01/18	Updated phototherapy requirement for psoriasis and added criteria for coverage to treat psoriatic arthritis.
BI568	Trenfya	06/01/18	Updated phototherapy requirement.
BI573	Benznidazole	06/01/18	New drug considered medically necessary for patients meeting the following criteria: 1) patient is between ages of 2 and 12, AND 2) patient has a diagnosis of American trypanosomiasis (Chagas disease).
BI574	Calquence	06/01/18	New drug used to treat mantle cell lymphoma. Oral specialty drug covered under the pharmacy benefit.
BI575	Mylotarg	06/01/18	New drug used to treat leukemia. Pre-authorization is required. Covered under the medical benefit as a specialty drug.
BI576	Trelegy Ellipta	06/01/18	New drug used to treat chronic obstructive pulmonary disease (COPD). Pre-authorization is required. Covered under the pharmacy benefit.
BI577	Verzenio	06/01/18	New drug used to treat advanced breast cancer. Pre-authorization is required. Oral specialty drug covered under the pharmacy benefit.
BI578	Viibryd	06/01/18	New drug used to treat depression. Pre-authorization is required. Covered under the pharmacy benefit.
BI579	Inhaled Corticosteroids	06/01/18	Preferred inhaled corticosteroids (Flovent, Arnuity Ellipta and Pulmicort Flexhaler) are covered with no utilization management edits. Non-preferred inhaled corticosteroids (Alvesco, Asmanex, Aerospan and QVAR) will be subject to a 120-day lookback for at least a 60-day trial of a preferred inhaled corticosteroid or claim will reject. Inhaled corticosteroid coverage may vary by formulary.

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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