Medical Policy Number |
Medical Policy Name |
Effective Date of Change |
Description of Changes |
BI012 |
Gynecomastia |
12/01/16 |
Updated coverage to include both men and women with a diagnosis of breast cancer. |
BI049 |
Hearing Aids |
01/01/17 |
Removed dollar limits; added coverage for specific hearing aids; added statement of recommendation by a licensed physician. |
BI055 |
Midwife |
01/01/17 |
Clarified verbiage that licensed mid wife services are covered when provided in a hospital setting. |
BI061 |
Trans-Cervical Balloon Tuboplasty |
12/01/16 |
Updated code 58345 to be considered diagnostic testing. |
BI101 |
Cartilage Transplants of Lower Extremity |
01/01/17 |
Added requirement for physicians to have validation of completed training program to do the procedure. |
BI119 |
Pulmonary Hypertension Pharmacy |
01/01/17 |
Added new drug Uptravi to policy. |
BI129 |
Tumor Markers |
01/01/17 |
Added coverage for additional indication for CEA antigen testing with diagnosis of invasive breast cancer. |
BI182 |
Intervertebral Disc Prostheses |
01/01/17 |
Due to lack of efficacy in clinical literature, two level cervical prosthetics disc replacement is no longer covered. Added code for revision of total disc arthroplasty, cervical, single interspace. |
BI196 |
Stereotactic Radiosurgery |
01/01/17 |
77295 (3 dimensional radiotherapy plan, including dose volume histogram) will be covered and can be billed with 77300 (basic radiation dosimetry calculation) |
BI198 |
Diabetic Shoes and Shoe Inserts |
01/01/17 |
Added codes for only diabetic complications that are more circulatory issues. |
BI217 |
Orthotic Devices and Orthotic Services |
01/01/17 |
Per Arkansas law �off-the-shelf� products (carried in stock and sold without therapeutic modification) do not meet the criteria for orthotics and are no longer covered. Defined Criteria for coverage and specific types of back braces. |
BI264 |
FEHBP Hearing Aids |
01/01/17 |
Removed all dollar limit amounts; removed verbiage on requiring recommendation from a physician. |
BI374 |
Inhaled Nitric Oxide |
12/01/16 |
Updated codes. |
BI394 |
Lumbar Spinal Fusion |
12/01/16 |
Updated codes. |
BI429 |
Dexamethasone Intravitreal Implant |
12/01/16 |
Added codes. |
BI431 |
Psychotherapy Coding |
12/01/16 |
Updated codes. |
BI459 |
Sylvant |
12/01/16 |
Added code for Siltuximab Injection. |
BI476 |
Digital Breast Tomosynthesis |
12/01/16 |
Updated codes. |
BI525 |
Vraylar |
01/01/17 |
New Drug: used to treat schizophrenia and bipolar disorder; requires pre-authorization. |