Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 09/18/1995	Title: Appetite Suppressants
Revision Date: 10/29/2004	Document: BI081:00
CPT Code(s):
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. The treatment of obesity is a specific contract exclusion in the certificate of coverage. Medications prescribed for suppressing appetite are not covered.
Medical Statement
Appetite suppressants are not covered. Medical services are rendered to a member for the care and treatment of an injury or disease. While obesity can contribute to injury or disease, QualChoice/QCA Health Plan recognizes behavioral change such as diet or exercise rather than drugs to suppress appetite as the appropriate care for obesity. Correspondingly, appetite suppressant medication or dietary supplements are considered medically unnecessary and are excluded from coverage. Biphetamine, Diethylporpion, Phendimetrazine, and Phentermine are all specific drugs indicated only for weight loss. There are other drugs such as Ritalin, Dexedrine, and Cylert which can also be prescribed for attention deficit disorder and narcolepsy as well as weight loss. Therefore, these drugs are covered by QualChoice/QCA Health Plan for the appropriate indications, but will be disallowed when prescribed for weight loss. All claims for drugs on the formulary exclusions list are rejected if submitted to QualChoice/QCA.
Limits
Not a covered benefit.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.