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: 01/01/2007	Title: Smoking & Tobacco Cessation
Revision Date: 06/01/2023	Document: BI183:00
CPT Code(s): 1000F, 4000F, 4001F, 99406, 99407
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 offers a smoking and tobacco cessation program, “Kick The Nic”, that allows the member two attempts to quit smoking or tobacco use per year. 2) Smoking and tobacco cessation services are not offered in all products. Refer to your Explanation of Coverage, Certificate of Coverage, Summary Plan Description, or Benefit Summary for coverage.
Medical Statement
1) For plans that have a smoking and tobacco cessation benefit, the QualChoice Smoking Cessation program allows the member up to 2 attempts to quit tobacco use per year. 2) Nicotine replacement therapy (NRT) as well as other drugs (e.g. varenicline, bupropion) used to treat smoking and tobacco cessation are covered under the pharmacy benefit. When billing for tobacco cessation, please review the following: a) Codes utilized for the tobacco cessation visit require preauthorization: i) 99406 - Intermediate tobacco cessation counseling (3 to 10 minutes). ii) 99407 - Intensive tobacco cessation counseling (greater than 10 minutes). b) Documentation should include the amount of time spent with the patient along with the assessment. Typically included in the assessment documentation are the following components: i) Ask about tobacco use ii) Advise the patient to quit iii) Access the willingness to attempt to quit iv) Assist with the attempt to quit c) The CPT code book has a category II classification system listing “F” codes that may be used to capture additional data to support quality performance measures. The “F” codes may be used in conjunction with an E&M visit to indicate clinical components of the E&M services. These codes are used to supplement your documentation by describing clinical services or results, but are not intended to replace category I codes. i) 1000F -Patient History- tobacco use assessed ii) 4000F -Tobacco use cessation counseling iii) 4001F- Tobacco use cessation intervention, pharmacologic therapy Codes Used In This BI: 1000F Patient History- tobacco use assessed 4000F Tobacco use cessation counseling 4001F Tobacco use cessation intervention, pharmacologic therapy 99406 Intermediate tobacco cessation counseling (3 to 10 minutes) 99407 Intensive tobacco cessation counseling (greater than 10 minutes)
Limits
Minimal cessation counseling of less than 3 minutes is not separately billable and should be considered a part of the evaluation and management visit.
Reference
Addendum: Effective 06/01/2023: Updated to reflect coverage of NRT products and other drugs under pharmacy 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.