Policy Updates March 2019

Important Information

Note - Some updates require the user to be logged into the website using username and password. Each secure section or policy will be marked with an asterisk *

Policies Status Update to Coverage
Policies With a Reduction in Coverage
We are changing how we reimburse for the following policies:

Perfusionist Services

*Facility Routine Services, Supplies and Equipment Reimbursement Policy - (R12)
  • We will deny claims submitted by a perfusionist for individual services when billed with Current Procedural Terminology (CPT®) codes 99190, 99191, and 99192.
  • Individual perfusionist services are not separately reimbursable and are included in the facility payment.
  • This update is effective for claims processed beginning March 17, 2019.

Ashkenazi Jewish Laboratory Panel

*Genetic Testing Panels - (R28)

Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis Coverage Policy (0514)
  • We will implement a new reimbursement policy, Genetic Testing Panels (R28), and update our Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis Coverage Policy (0514).
  • If individual gene tests that make up an Ashkenazi Jewish laboratory panel are billed separately, the individual gene codes will be rebundled into the appropriate single panel code (CPT 81412), and reviewed for medical necessity.
  • This policy is effective for dates of service beginning March 18, 2019.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective March 15, 2019:
Ablative Treatments for Malignant Breast Tumors – (0540) New
  • Consolidates content from three coverage policies being retired:
    • Cryoablation of Breast Lesions - (0311)
    • Microwave Thermotherapy for Breast Cancer - (0290)
    • Radiofrequency Ablation for Breast Cancer - (0449)
  • No change in current coverage.
Flow Cytometry – (0538) New
  • Advance notification of policy effective May 20, 2019.
Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation – (0539) New
  • Remains EIU.
  • Contains policy statement position and information from three policies:
    • Omnibus Codes – (0504).
    • eviCore cobranded policy - Spinal Cord and Implanted Peripheral Nerve Stimulation.
    • Spinal Cord and Implanted Peripheral Nerve Stimulation (retired in 2016).

Stem Cell Transplantation: Non-Cancer Disorders – (0535)

 New
  • Consolidates content from six coverage policies being retired:
    • Stem-Cell Transplantation for Aplastic Anemia and Fanconi Anemia – (0293)
    • Stem-Cell Transplantation for Autoimmune Diseases/Miscellaneous Conditions – (0357)
    • Stem-Cell Transplantation for Inherited Metabolic Disorders – (0386)
    • Stem-Cell Transplantation for Myelofibrosis and Polycythemia Vera – (0429)
    • Stem-Cell Transplantation for Primary Immunodeficiency Disorders – (0378)
    • Stem-Cell Transplantation for Sickle Cell Disease and Thalassemia Major – (0464)
  • No changes in existing coverage.
Ambulatory Assistance Devices - (0050) Modified
  • Important change in coverage criteria:
    • Updated and clarified wording in existing policy statements for certain walkers.
Complementary and Alternative Medicine - (0086) Modified
  • Important changes in coverage criteria:
    • Added four additional therapies to existing EIU policy statement:
      • Wilderness therapy
      • Recreational therapy
      • Outdoor youth programs
      • Pet therapy
Miscellaneous Musculoskeletal Procedures – (0515) Modified
  • Important change in coverage criteria:
    • Added EIU policy statement for in-office diagnostic arthroscopy.
Surgical Treatment for Hyperhidrosis – (0037) Modified
  • Important changes in coverage criteria:
    • Revised scope of policy:
      • Addresses surgical treatments only.
      • Title updated.
    • Updated criteria language about prerequisites before approving surgery.
    • Updated existing endoscopic thoracic sympathectomy (ETS) policy statement to remove language related to methods of performing ETS.
    • Clarified existing surgical removal policy statement noting excision of sweat glands can include use/combination of curettage and liposuction.
    • Updated EIU list.
Tilt Table Testing - (0066) Modified
  • Important changes in coverage criteria:
    • Added indication “differentiation of convulsive syncope from epilepsy” to existing covered policy statement.
Transcranial Magnetic Stimulation - (0383) Modified
  • Important changes in coverage criteria:
    • Added number of treatments.
    • Added “administered in an outpatient setting”.
    • Added “validated depression monitoring scales are administered at the beginning and at the end of the initial and each subsequent course of TMS”.
Ultrasound in Pregnancy (including 3D, 4D and 5D Ultrasound) – (0142) Modified
  • Important changes in coverage criteria:
    • Added five-dimensional (5D) ultrasound to existing EIU policy statement.
Three policies retired, content added to Ablative Treatments for Malignant Breast Tumors – (0540) Retired
  • Cryoablation of Breast Lesions - (0311)
  • Microwave Thermotherapy for Breast Cancer - (0290)
  • Radiofrequency Ablation for Breast Cancer - (0449)
Six policies retired, content added to Stem Cell Transplantation: Non-Cancer Disorders – (0535) Retired
  • Stem-Cell Transplantation for Aplastic Anemia and Fanconi Anemia – (0293)
  • Stem-Cell Transplantation for Autoimmune Diseases/Miscellaneous Conditions – (0357)
  • Stem-Cell Transplantation for Inherited Metabolic Disorders – (0386)
  • Stem-Cell Transplantation for Myelofibrosis and Polycythemia Vera – (0429)
  • Stem-Cell Transplantation for Primary Immunodeficiency Disorders – (0378)
  • Stem-Cell Transplantation for Sickle Cell Disease and Thalassemia Major – (0464)
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • No new or updated policies for March 2019.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
The following Cigna-eviCore Cobranded Comprehensive Musculoskeletal Management (CMM) guidelines have been updated Modified
  • Epidural Steroid Injections – (CMM 200)
    • Clarified selective nerve root blocks (SRNB) as diagnostic or therapeutic SRNB.
    • Changed therapeutic SNRBs from not medically necessary (NMN) to EIU.
    • Change SNRB injections from two weeks to seven days between injections.
    • Clarified the epidural steroid injection (ESI) section.
  • Hip Surgery Arthroscopic and Open – (CMM 314)
    • Clarified the Tonnis grade 2 and 3 descriptions.
    • Added “in-office dx arthroscopy” to EIU section.
  • Knee Replacement Arthroplasty – (CMM 311)
    • Expanded total knee replacement (TKR) criteria to include tibial, femoral, or patellofemoral compartment rather than tibiofemoral.
Policies Status Details
Administrative Policies
  • No updates for March 2019.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
  • No additional new, modified, or retired policies for March 2019.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • One policy updated for March 2019.
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
  • No updates for March 2019.

These policies apply to health benefit plans administered by Cigna companies and are intended to provide guidance in interpreting certain standard Cigna benefit plans. Please note, the terms of a customer's particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these policies are based. For example, a customer's benefit plan document may contain a specific exclusion related to a topic addressed in a policy. In the event of a conflict, a customer's benefit plan document always supersedes the information in the policies.
In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including these policies and; 4) the specific facts of the particular situation. These policies relate exclusively to the administration of health benefit plans and are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.