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QualChoice Health Insurance  ♦  November 3, 2016

New and Amended Medical Policies

Medical Policy Number Medical Policy Name Effective Date of Change Description of Changes
BI007 Electro Diagnostic Testing 11/01/16 Added specified reimbursement criteria for Physical and Occupational therapists, performing the study.
BI158 Obesity Surgery 11/01/16 Clarified verbiage that Pediatric obesity surgery is not covered.
BI401 Xeljanz 11/01/16 Updating to add extended release product drug to use once a day versus twice a day but is still subject to step therapy.
BI458 Cyramza 11/01/16 Added additional indications.
BI517 Makena 11/01/16 New policy; drug to help with preterm labor.

Coming Amendments

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.
View all QualChoice Medical Policies.
For questions or more information call QualChoice: 501.228.7111 or 800.235.7111
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