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.

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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: 01/01/2016	Title: Unituxin (Dinutuximab)
Revision Date:	Document: BI493:00
CPT Code(s): None
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. 1) Unituxin (Dinutuximab) requires prior authorization. 2) Unituxin is used to treat high-risk Neuroblastoma in pediatric patients. 3) Unituxin is a specialty drug covered under the medical benefit.
Medical Statement
Unituxin (Dinutuximab) is considered medically necessary for members meeting the following criteria: 1) Pediatric patient with diagnosis of high-risk Neuroblastoma who have achieved partial response to prior first-line multi-agent, multi-modality therapy (i.e. induction combination chemotherapy, myeloblative consolidation chemotherapy followed by autologous stem cell transplant, and radiation therapy) AND 2) Being used in combination with GM-CSF, interleukin-2, and 13-cis-retinoic acid 3) Unituxin is considered experimental and investigational for all other uses
Limits
Coverage is provided for up to 24 weeks to accommodate a maximum of 5 cycles (cycles 1, 3, and 5 are 24 days in duration; cycles 2 and 4 are 32 days in duration).
Reference
1) Unituxin Prescribing Information. United Therapeutics Corp. Silver Spring, MD. March 2015. 2) Clinical Pharmacology. Accessed online November 13, 2015.
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.