Coverage Policies

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

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.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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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.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 08/01/2008 Title: Infusion Codes
Revision Date: Document: BI006:00
CPT Code(s): A4206-A4232, 96360-96379, 96401-96549
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)    QualChoice covers infusions of medications in participating physicians’ offices, participating infusion centers, and participating hospital outpatient departments.

2)    This policy restates rules that are present in the national standard coding books about what services are included in the infusion charges.


Medical Statement

1)    The following wording appears in the CPT book in the general description of “Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy)” and again in the general description of “Chemotherapy Administration”

a)    “If performed to facilitate the infusion or injection, the following services are included and are not reported separately:

i)     “Use of local anesthesia

ii)    “IV start

iii)   “Access to indwelling IV, subcutaneous catheter or port

iv)   “Flush at conclusion of infusion

v)    “Standard tubing, syringes and supplies.”

2)    In view of this definitional statement, charges for syringes, needles, tubing, infusion sets and supplies will not be paid by QualChoice, as the pricing for the infusions clearly is intended to cover these items.

 

Codes Used In This BI:

A4206

1 CC sterile syringe&needle

A4207

2 CC sterile syringe&needle

A4208

3 CC sterile syringe&needle

A4209

5+ CC sterile syringe&needle

A4210

Nonneedle injection device

A4211

Supp for self-adm injections

A4212

Non coring needle or stylet

A4213

20+ CC syringe only

A4215

Sterile needle

A4216

Sterile water/saline, 10 ml

A4217

Sterile water/saline, 500 ml

A4218

Sterile saline or water

A4220

Infusion pump refill kit

A4221

Maint drug infus cath per wk

A4222

Infusion supplies with pump

A4223

Infusion supplies w/o pump

A4230

Infus insulin pump non needl

A4231

Infusion insulin pump needle

A4232

Syringe w/needle insulin 3cc

96360

Hydration iv infusion init

96361

Hydrate iv infusion add-on

96365

Ther/proph/diag iv inf init

96366

Ther/proph/diag iv inf addon

96367

Tx/proph/dg addl seq iv inf

96368

Ther/diag concurrent inf

96369

Sc ther infusion up to 1 hr

96370

Sc ther infusion addl hr

96371

Sc ther infusion reset pump

96372

Ther/proph/diag inj sc/im

96373

Ther/proph/diag inj ia

96374

Ther/proph/diag inj iv push

96375

Tx/pro/dx inj new drug addon

96376

Tx/pro/dx inj same drug adon

96379

Ther/prop/diag inj/inf proc

96401

Chemo anti-neopl sq/im

96402

Chemo hormon antineopl sq/im

96405

Chemo intralesional up to 7

96406

Chemo intralesional over 7

96409

Chemo iv push sngl drug

96411

Chemo iv push addl drug

96413

Chemo iv infusion 1 hr

96415

Chemo iv infusion addl hr

96416

Chemo prolong infuse w/pump

96417

Chemo iv infus each addl seq

96420

Chemo ia push tecnique

96422

Chemo ia infusion up to 1 hr

96423

Chemo ia infuse each addl hr

96425

Chemotherapy infusion method

96440

Chemotherapy intracavitary

96446

Chemotx admn prtl cavity

96450

Chemotherapy into cns

96521

Refill/maint portable pump

96522

Refill/maint pump/resvr syst

96523

Irrig drug delivery device

96542

Chemotherapy injection

96549

Chemotherapy unspecified


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.
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