Provider Quick Alert

April 1, 2020
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
BI038   C
Genetic Testing 01/01/20 Codes updated.
BI063   C
Non Face-to-Face Services
01/01/20
Codes updated.
BI129   C
Tumor Markers 01/01/20 Codes updated.
BI272   C
Obstetrical Ultrasound
01/01/20
Updated codes regarding ultrasounds for more than one fetus, per pregnancy.
BI306   C
Obstructive Sleep Apnea 01/01/20 Updated codes to include G47.9 Other Sleep Disorders, to be covered for home sleep studies.
BI258  V
Stelara
03/01/20
Clarified coverage/billing details regarding IV and SC dosage forms.
BI344  V
Physician Extenders
03/01/20
Not eligible for reimbursement of Level 5 EM codes (99205, 99215, 99285). Direct physician involvement is expected at this level.
BI063   C
Non Face-to-Face Services 03/15/20 99441-99443 telephonic services temporarily covered (3/15/2020-5/15/2020) due to COVID-19 pandemic.
BI062  V
Preventive Health Benefit
04/01/20
Updated Hepatitis C screening per new USPSTF recommendations (ages 18-79).
BI169  V
Macular Degeneration Treatments and Diabetic Macular Edema Treatments
04/01/20
Stated Beovu is not covered.
BI372   C
Women's Preventive Health Benefit
04/01/20
Laparoscopic salpingectomy (55861) covered as preventive for sterilization.
BI446  V
Fycompa
04/01/20
Included coverage for partial-onset seizures for ages 4 and up and added coverage for tonic-clonic seizures.
BI538  V
Kisqali
04/01/20
Included use in pre- and perimenopausal women with an aromatase inhibitor or with fulvestrant in postmenopausal women.
Comi ng Amendments

Medical Policy Number
Medical Policy Name Effective Date of Change Description of Changes
BI133  V C
Hematopoietic Colony-Stimulating Factors 05/01/20 Included HCPCs for fulphila and udenyca; added coverage for Ziextenzo.
BI157   V
Immune Globulin 05/01/20 Included Xembify as covered product.
BI250  P New
Saphris 05/01/20 Added coverage criteria for Secuado.
BI643   New
Brukinsa 05/01/20 Used to treat mantle cell lymphoma (MCL); requires pre-authorization. Oral specialty drug; must be obtained through a contracted specialty pharmacy.
BI644   New
Enhertu
05/01/20
Used to treat advanced or unresectable breast cancer; requires pre-authorization. Considered a specialty medication.
BI645   New
Inrebic 05/01/20 Used in the treatment of myelofibrosis; requires pre-authorization. Oral specialty drug; must be obtained through a contracted specialty pharmacy.
BI646   New
Padcev
05/01/20
Used to treat advanced urothelial cancer; requires pre-authorization. Specialty drug covered under the medical benefit.
BI647   New
Reblozyl 05/01/20 Used to treat anemia in adult patients with beta thalassemia; requires pre-authorization and is a specialty medication.
BI648   New
Rozlytrek
05/01/20
Used to treat solid tumors with specific characteristics; requires pre-authorization. Oral specialty drug; must be obtained through a contracted specialty pharmacy.
BI649   New
Trikafta 05/01/20 Used in the treatment of cystic fibrosis; requires pre-authorization. Oral specialty drug; must be obtained through a contracted specialty pharmacy.
BI650   New
Vascepa
05/01/20
Used to treat severe hypertriglyceridemia; requires pre-authorization.
BI651   New
Wakix 05/01/20 Used to treat sleepiness (EDS) in adults with narcolepsy; requires pre-authorization. Considered a specialty drug; must be obtained through a contracted specialty pharmacy.
BI652   New
Adakveo
05/01/20
Used to reduce vasocclusive crises (VOCs) in patients age 16 and older with sickle cell disease (SCD); requires pre-authorization. Considered a specialty medication.
BI171   CP
Rituximab 06/01/20 Updated policy to require trial of Truxima (rituximab biosimilar) before brand name Rituxan is approved.
BI371  V
Xyrem
06/01/20
Updated coverage criteria to include previous trial of Wakix for excessive daytime sleepiness.
BI447  V
Imbruvica
06/01/20
Included Brukinsa as prerequisite therapy prior to Imbruvica for MCL.
BI642   New
Asparlas (calaspargase pegol-mknl)/Oncaspar (pegaspargase)
06/01/20
Used to treat acute lymphoblastic leukemia (ALL). Both require pre-authorization and are considered specialty drugs.
For questions about QualChoice Medical Coverage Policies, please contact your Provider Relations Representative 
at 800.235.7111 or 501.228.7111, ext. 7004, Monday through Friday, 8:00 a.m. to 5:00 p.m.

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