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: 10/10/2013	Title: Breast Cancer Prophylaxis
Revision Date: 11/01/2014	Document: BI430:00
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. Tamoxifen (Soltamox) and Raloxifene (Evista) are considered a preventive benefit, for breast cancer prophylaxis in women at high risk for breast cancer. 2. Raloxifene requires pre-authorization.
Medical Statement
1) Tamoxifen is covered as a preventive benefit under the following criteria: a) The member is female age 35 years or more AND; b) There is no previous history of breast cancer or Lobular Carcinoma In Situ (LCIS) or Ductal Carcinoma In Situ (DCIS) AND; c) The member has a 5 year cancer risk > 3% using National Cancer Institute Breast Cancer Risk Assessment Tool, located at: http://www.cancer.gov/bcrisktool/ 2) Raloxifene(Evista) is covered as a preventive benefit when the above criteria are met AND tamoxifen cannot be used. Raloxifene requires pre-authorization
Background
The USPSTF recommends this as a level B recommendation.
Reference
USPSTF Guidelines at: http://www.uspreventiveservicestaskforce.org/uspstf13/breastcanmeds/breastcanmedsrs.htm#consider
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.