Medical Policy Updates - September 2019

Provider Quick Alert

August 30, 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
BI423	GLP-1 Agonists	01/03/19	Retired policy.
BI453	Corticosteriod Beta Agonist Combo Products	01/03/19	Retired policy.
BI527	Proton Pump Inhibitors	01/03/19	Retired policy.
BI579	Inhaled Corticosteriods	01/17/19	Retired policy.
BI058	Respite Care	04/01/19	Retired policy.
BI219	Bariatric Surgery-Unity Health	04/01/19	Retired policy.
BI315	Sylatron	04/01/19	Retired policy.
BI335	Krystexxa	04/01/19	Retired policy.
BI429	Dexamethasone Intravitreal Implant (Ozurdex)	04/01/19	Retired policy.
BI444	Trokendi XR	04/01/19	Retired policy.
BI526	Zurampic	06/01/19	Retired policy.
BI014	Arterial Catheterization (CABG Charges)	07/01/19	Retired policy.
BI035	Autopsy	07/01/19	Retired policy.
BI037	Hospital PASS	07/01/19	Retired policy.
BI571 V	Impella (pVAD)	08/01/19	Added references regarding SYNTAX and jeopardy scores to quantify PCI risk.
BI038 V	Genetic Testing	09/01/19	New CPT codes added and fetal genetic testing codes removed (see BI205).
BI079 V	Botox	09/01/19	Added CGRP inhibitors to migraine prophylaxis medications.
BI205 V , C	Fetal Genetic Testing	09/01/19	Quad test coverage added and code 81422 with pre-authorization.
BI238 V , C	HPV Testing	09/01/19	Code 0096U added for urine test. Further distinction and clarification of preventive vs. medical HPV testing.
BI544	Cycloset	09/01/19	Retired policy.

Comi ng Amendments

Medical Policy Number	Medical Policy Name	Effective Date of Change	Description of Changes
BI199 V	Noxafil	10/01/19	Updated to reflect coverage of all dosage forms of Noxafil.
BI334 V	Adcetris	10/01/19	Updated coverage criteria for non-Hodgkin's T cell lymphomas, primary cutaneous CD30+ T cell lymphoproliferative disorder, and mycosis fungoides/Sezary syndrome.
BI356 V	Jakafi	10/01/19	Updated to include approved indication for steroid-refractory graft-versus-host disease (GVHD).
BI478 V	Entyvio	10/01/19	Updated to add reauthorization criteria.
BI622 New	Balversa	10/01/19	Used to treat urothelial carcinoma. Requires pre-authorization. Oral specialty drug, covered under pharmacy benefit.
BI623 New	Corlanor	10/01/19	Used to treat a type of heart failure. Requires pre-authorization. Covered under pharmacy benefit.
BI624 New	Endari (L-glutamine)	10/01/19	Used to reduce acute complications of sickle cell disease (SCD). Requires pre-authorization. Covered under pharmacy benefit.
BI625 New	Evenity	10/01/19	Used to treat osteoporosis in postmenopausal women at high risk for fracture. Requires pre-authorization. Specialty injection, covered under medical benefit.
BI626 New	Kineret	10/01/19	Used to treat rheumatoid arthritis, cryopyrin-associated periodic syndromes (CAPS) and neonatal-onset multisystem inflammatory disease (NOMID). Requires pre-authorization. Specialty drug, covered under pharmacy benefit.
BI627 New	Libtayo	10/01/19	Used to treat cutaneous squamous cell carcinoma (CSCC). Requires pre-authorization. Specialty medication, covered under medical benefit.

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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