Medical Policies

Medical Policies

Learn about QualCare’s medical coverage policies which describe our evaluation and coverage of medical procedures, devices, and medications. We rely on evidence- based medical research and peer-reviewed literature to establish coverage policies.

Effective December 3, 2018

QualCare, Inc., a Cigna company, is using Cigna medical coverage policies, including injectable drugs and biologic therapy policies, to make medical necessity and other clinical coverage determinations.

View the Cigna coverage policies on the Cigna for Health Care Professionals website ( > Resources > Coverage Policies).

QualCare is not a pharmacy benefits manager (PBM) for self-administered prescription medications. Please refer to your plan’s PBM for information about coverage for self-administered prescription medications. Coverage criteria for injectable (not self-injectable) drugs and biologic therapies are available through the link above. Coverage criteria for self-administered prescription medications in general are not applicable to QualCare administered plans.

Prior to December 3, 2018

QualCare, Inc. Medical Polices are listed below.


Acne Treatment- Interventional procedures (rvsd2017)

Actigraphy (rvsd 2017)

Acupuncture (rvsd 2018)

Acute Inpatient Treatment for Eating Disorders (rvsd 2017)

Acute Inpatient Treatment for Substance Use Disorders (rvsd 2017)

Alternating Electric Field Therapy (rvsd2018)

Amniocentesis (rvsd 2018)

Anti-Tumor Necrosis Factor therapy( TNF)(new 2016)

Anticoagulation Therapy-Preoperative (rvwd 2018)

Applied Behavioral Analysis (Lovaas Therapy) (rvsd 2017)

Auditory Brainstem Implants (rvsd2018)

Benlysta (Belimumab) (rvsd 2018)

Biofeedback for Urinary Incontinence (rvsd2018)

Bioidentical Compounded Hormone Replacement Therapy (rvsd 2018)

Bisphosphonates for Injection (rvsd 2018)

Blepharoplasty (rvsd 2018)

Bloodless Surgery (rvsd 2017)

Bone Growth Stimulator (rvsd 2018)

Bone-Anchored Hearing Aid (BAHA) (rvsd 2018)

Botulinum Toxin (rvsd2018)

Brachytherapy for In-Stent Restenosis in Native Coronary Arteries (rvsd 2011)

BRCA Testing (rvsd 2017)

Breast Cancer Gene Expression Assays (rev 2017)

Breast Ductal Lavage and Fiberoptic Breast Ductoscopy (rvsd2018)

Breast Imaging (rvsd 2018)

Bronchial Thermoplasty (rvsd 2018)

Cardiac Rehabilitation (rvwd 2018)

Cervical Cancer (HPV) Vaccine (rvsd 2015)

Cervical Cancer Screening (rvsd 2017)

Cervical Spine Traction Devices for Home Use (rvsd2017)

Chelation Therapy(Parenteral) (rvsd2017)

Chest Computerized Tomographic (CT) Scan for Screening (rvsd 2011)

Chiropractic Care (rvsd2017)

Clean Claim Definition

Clinical Trials (rvwd 2018)

Cochlear Implants (rvsd 2018)

Cognitive Rehabilitation Therapy (rvsd 2018)

Cold Laser Therapy (rvsd 2018)

Colorectal Cancer Screening (rvwd 2018)

Continuous Passive Motion Devices (rvsd2017)

Corneal Topography (rvsd 2018)

Coronary Artery Calcium Scoring (rev 2017)

Cryotherapy with Cold Compression Devices (rvsd2017)

CT Angiography (rev 2017)

Denosumab ( Prolia® and Xgeva®) (rvsd 2017)

Drug and Alcohol Detoxification (rvsd 2017)

Drug Testing (rvsd 2017)

Drug, Device or Biologic (Off-Label Use) (rvwd 2018)

Eculizumab (Soliris) (rvsd 2018)

Electrical Stimulation Therapy for Wounds (rvsd 2018)

Endoscopic and Minimally Invasive Management of Gastroesophageal Reflux Disease (rev 2017)

Enhanced External Counterpulsation (EECP) (rvwd 2018)

Enteral and Oral Feeding (rvsd 2018)

Epidural Injection (rvwd 2018)

Evoked Potential (EP) Studies - Intraoperative (rvwd 2012)

Extracorporeal Shock Wave Therapy (ESWT), for Musculoskeletal Conditions and Soft Tissue wound (rvsd 2018)

Extracorporeal Shock Wave Therapy (ESWT, Orthotripsy [podiatricorthopedic applications]) (rvwd 2016)

Facet Joint Injections and Facet Joint Denervation (rev 2017)

Fentanyl (rvsd 2014)

Fetal Cord Blood (rvwd 2012)

First Trimester Screening Genetic Abnormalities (rvsd 2017)

Foot Care (rvsd 2018)

Foot Orthotics and Diabetic Shoes (rvwd 2018)

Gastric Bypass and Other Bariatric Surgical Procedures (rvsd 2018)

Gender Reassignment Surgery (rvwd 2018)

Genetic Testing (rev 2017)

Genetic Testing for Susceptibility to Colorectal (rvsd 2018)

Glucose Monitoring (Continuous, Interstitial Fluid) (rvsd 2017)

Gonadotropin-releasing hormone agonists and antagonists

Growth Hormone therapy(rvsd 2018)

Histrelin acetate subcutaneous implant (rvsd 2018)

Hyaluronan Injections (Viscosupplementation (rvsd 2018)

Hyperbaric Oxygen Therapy (rvsd 2017)

Hysteroscopic Sterilization Procedures (rvwd 2014)

Implantable Testosterone Replacement Therapy for Adult Male Hypogonadism (Testopel) (rvsd2017)

Infertility Diagnostic (rvsd 2017)

Infertility Therapeutic (rvsd 2017)

Influenza Vaccination (rvsd 2016)

Injectable Infliximab ("Remicade") (rvsd 2013)

Insulin Pump (rvsd 2018)

Intensive Outpatient Treatment for Eating Disorders (rvsd 2017)

Intensive Outpatient Treatment for Substance Use Disorders (rvsd 2017)

Intervertebral Disc Prostheses (rvwd 2018)

Intracoronary Brachytherapy for In-Stent Restenosis (rvsd 2016)

Intradiscal Electrothermal Therapy IDET (rvwd 2011)

Intraocular Lens IOL (rvsd 2018)

Intraoperative Neurophysiology Monitoring IONM (rvsd 2018)

Intrastromal Corneal Ring Segments (new 2011)

Intravenous and Subcutaneous Immunoglobulin (rvwd 2018)

Intravenous Iron Therapy (rvwd 2018)

IOPEatingDisorders (new2015)

IV Iron (rvsd 2014)

Keloid Treatment and Scar Revision rvsd 2018

Kyphoplasty and Vertebroplasty (rvsd2017)

Laser Treatment of Plaque Psoriasis (rev 2017)

Lung cancer screen (rvsd 2018)

Lupron (leuprolide) and other injectable or GnRH Analogs (rvsd 2016)

Lyme disease (rvwd 2018)

Marijuana for Medical Use (rvwd 2018)

Mastectomy for Gynecomastia rvsd 2018

Medical Necessity – Definition (rvsd 2018)

Meningococcal Vaccine (rvsd 2013)

Naltrexone extended-release injectable suspension Vivitrol (rvsd 2018)

New Technology AssessmentNew Policies (rvsd 2017)

NJ State-Mandated Early Intervention System (EIS) (rvsd2017)

Non-Invasive Hepatic Fibrosis Testing (rvsd 2018)

Nutritional Counseling (rvwd 2018)

Obstetrical ultrasound (rvwd 2018)

Obstructive Sleep Apnea (OSA) (rvsd2017)

Obstructive Sleep Apnea Diagnostic Testing In Adults (rvsd2018)

Off Label Use (rvwd 2014)

Omalizumab (Xolair) (rvsd 2018)

Orthognathic Surgery (rsvd 2017)

Oxygen Therapy for Home Use (rvsd2017)

PancraGEN Molecular Pathology Test (rvsd 2018)

Partial Hospitalization for Eating Disorders (rvsd 2017)

Partial Hospitalization for Substance Use Disorders (rvsd 2017)

Pegloticase (Krystexxa®) (rvsd 2017)

Percutaneous Left Atrial Appendage Closure Procedures (rvsd 2017)

Percutaneous Left Atrial Occlusion (new2015)

PET (Positron Emission Tomography) Scan (rvsd 2017)

PHP Eating Disorder (new2015)

Platelet Rich Plasma (rvsd 2017)

Pneumatic Compression Devices and Compression Garments (rvsd 2017)

Pre-implantation Genetic Diagnosis (rvsd 2017)

Preconception Genetic Carrier Screening (rvsd 2018)

Preventative and Wellness Practice Guidelines

Progesterone To Prevent Pre-Term Delivery (rvsd 2018)

Prolotherapy (rvsd 2018)

Prothrombin Time Home Monitoring (rvsd 2017)

Proton Beam Therapy (rvsd 2018)

Pulmonary Rehabilitation (rvsd 2018)

Pulsed Electrical Stimulation for Arthritis (BioniCare® System) (rvsd 2018)

Reconstruction Post Breast Surgery (rev 2017)

Recurrent pregnancy loss (rvsd 2018)

Reduction Mammoplasty (rvwd 2018)

Refractive Eye Surgery (rvsd 2018)

Residential Substance Use Disorders Treatment (rvsd 2017)

Respiratory Syncytial Virus (RSV) Prophylaxis with Synagis (rvsd 2018)

Sacral Nerve Stimulation for Urinary voiding (rvsd 2018)

Selective Internal Radiation Therapy (SIRT) (rvsd 2017)

Shingles (Zoster) Vaccine (rvsd 2018)

Single Photon Emission Computed Tomography (SPECT) (rvsd 2017)

Skeletal Manipulation under Anesthesia (rvsd 2018)

Sleep-Disordered Breathing Testing (rvsd 2011)

Specimen Provenance Testing in Laboratory and Surgical Pathology (rvsd2017)

Speech Therapy (rvsd2017)

Spinal Fusion Surgery (rvsd2017)

Stereotactic Radiosurgery and Radiotherapy (rev 2017)

Sural Nerve Graft with Or Following Radical Prostatectomy (rvsd 2018)

Testosterone Replacement (new2015)

Thermal Annular and Intradiscal Procedures for Discogenic Back Pain(rvsd 2013)

Thermal Annular and Intradiscal thermal ablation Procedures (rvsd2017)

Thyrogen (rvsd 2018)

Topographic Genotyping (PathFinderTG, PancraGEN) (rvsd 2018)

Transcranial Magnetic Stimulation (rvsd 2017)

Transmucosal Immediate Release Fentanyl (rev 2017)

Transvaginal Ultrasonography (non-obstetrical) (rvsd2017)

Trigger Point Injections (rvsd 2018)

Tumor Chemotherapy Sensitivity and Resistance Assays (rvsd 2017)

Umbilical Cord Blood Banking (rvsd 2017)

Vacuum-Assisted Negative Pressure Wound Therapy (rvsd 2018)

Varicose Vein Interventions (Lower Extremities) (rvsd 2018)

Vedolizumab (Entyvio®) (rvsd 2018)

Victoza (liraglutide [rDNA origin] injection) (new 2011)

Video and Ambulatory EEG Monitoring (rvsd 2018)

Vitamin B-12 Therapy (injectable) (rvsd 2017)

Weight Loss Treatment (non-surgical) (rvsd 2018)

Wellness Benefits Adult and Pediatric (rev 2017)

Whole Body Cutaneous Photography (WBCP) (rvsd 2018)

Wigs (rvsd 2017)

Wireless Capsule Endoscopy (rvsd2017)

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Copyright © 2016 QualCare, Inc. (dba QANI Administrators), A Cigna Company. Some content provided under license.