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 Evolent. 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: Abortion

Revision Date: 11/01/2014

Document: BI206:00

CPT Code(s): 59840, 59841, 59850-59852, 59855-59857, 59866

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) Elective termination of pregnancy is not a covered service.

2) Therapeutic termination of pregnancy requires preauthorization, and will only be authorized if the mother’s life is endangered by continuation of the pregnancy. Documentation of concurrence of two additional network physicians that the mother’s life is endangered is required.

3) Any costs entailed in the performance of or in complications arising from any non-covered termination of pregnancy are not covered.

Medical Statement

1) Elective termination of pregnancy is not covered.

2) Therapeutic termination of pregnancy is covered, with preauthorization, only when determined to be Medically Necessary because the mother’s life is endangered by continuation of the pregnancy (the surgeon who would be performing the procedure should request the pre-authorization with documentation of second opinions from two independently practicing physicians who can speak to the risk posed to the mother’s life from continuation of the pregnancy).

3) Associated anesthesia and facility charges (if any) and the care of complications caused by any non-covered termination of pregnancy are also not covered.

4) The following are examples of conditions where the life of the mother could be endangered if the fetus was carried to term:

a) Severe psychiatric impairment (as evidenced by prior institutionalization or prior suicidal attempts)

b) Severe cardiac disease (prior history of cardiac decompensation)

c) Cancer (carcinoma of the cervix, breast, or uterus)

d) Advanced hypertensive cardiovascular disease

e) Severe renal disease (on renal dialysis, severe renal impairment due to either chronic or acute kidney disease)

f) Intracranial aneurysms (history of prior intracranial bleeding)

g) History of repeated and severe postpartum hemorrhage with prior pregnancies

h) Severe diabetes

i) Blood clotting abnormality resulting in a high risk of bleeding or clotting.

Codes Used In This BI:

59840	Abortion
59841	Abortion
59850	Abortion
59851	Abortion
59852	Abortion
59855	Abortion
59856	Abortion
59857	Abortion
59866	Abortion (mpr)

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.