Policy Updates August 2021

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 Update to Coverage
Policies With a Reduction in Coverage
  • There were no additional updates for August 2021 that resulted in a reduction in coverage.
Policies Status Details
Medical Coverage Policies
  • Unless otherwise noted, the following medical coverage policies were modified effective August 15, 2021:
Anesthesia and Facility Services for Dental Treatment – (0415) Modified
  • Important change in coverage criteria:
    • Added criteria to existing policy statement covering monitored anesthesia care (MAC)/general anesthesia when local anesthesia is not appropriate or indicated.
Atherosclerotic Cardiovascular Disease Risk Assessment: Emerging Laboratory Evaluations – (0137) Modified
  • Important change in coverage criteria:
    • Added plasma ceramides (e.g., MI-Heart Ceramides) to existing experimental, investigational or unproven (EIU) policy statement addressing screening, diagnosing or management of coronary heart disease.
Breast Reduction – (0152) Modified
  • Important changes in coverage criteria:
    • Updated title from “Reduction Mammoplasty” to current title.
    • Added not medically necessary policy statement addressing correction of benign inverted nipples.
Cardiac Rehabilitation (Phase II Outpatient) – (0073) Modified
  • Advance notification of important changes in coverage criteria, effective November 15, 2021:
    • Added EIU policy statement addressing virtual/remote home-based or hybrid cardiac rehabilitation program.
Inpatient Admission for Radiation Therapy – (0408) Modified
  • Important change in coverage criteria:
    • Clarified existing policy statement for inpatient admission for radiation therapy.
Molecular Diagnostic Testing for Hematology and Oncology Indications – (0520) Modified
  • Important changes in coverage criteria:
    • Updated criteria for breast cancer index test.
    • Added new EIU policy statement addressing adhesive patch gene expression assay for pigmented skin lesions.
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Electric Stimulation for Pain, Swelling and Function in a Clinic Setting – (CPG 272) Modified
  • Important changes in coverage criteria:
    • Added EIU policy statement addressing Neufit Neubie device.
    • Added clinical statement addressing sensory loss and use of electric stimulation.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Pacemaker (Cardiac Rhythm Implantable Device) Guidelines Modified
  • Minor changes in coverage criteria/policy, posting and effective September 1, 2021:
    • No significant clinical updates.
    • Minor nonclinical changes in Preface section and section 1.
    • Minor formatting/wording changes in CRID-7.3: Indications for Asymptomatic Patients page 12.
Sleep Disorders and Treatment Guidelines Modified
  • Important changes in coverage criteria, posted August 15, 2021, effective September 15, 2021:
    • Expanded home sleep apnea testing indications including individuals with one of the comorbid indications for attended sleep studies in in-laboratory polysomnography section stating testing can be done in facility or in home if treating provider prefers.
    • Expanded proper uses of polysomnography in pediatric patients indications by addressing where positive airway pressure titration may be performed without a baseline study for sleep-related hypoventilation.
Policies Status Details
Administrative Policies
  • No updates for August 2021.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective August 1, 2021:
Avatrombopag - (IP0152)
  • Replaces Avatrombopag – (P0079).
Cyanocobalamin Nasal Spray – (IP0170)
  • Replaces Cyanocobalamin Nasal Spray – (P0097).
Desmopressin Sublingual Tablets - (IP0127)
Eltrombopag - (IP0153)
  • Replaces Eltrombopag – (9003).
Fostamatinib - (IP0154)
  • Replaces Fostamatinib – (P0081).
Glycerol Phenylbutyrate - (IP0169)
  • Replaces Glycerol Phenylbutyrate - (P0113).
Ibalizumab-uiyk - (IP0171)
  • Replaces Ibalizumab-uiyk – (M0001).
Lusutrombopag - (IP0156)
  • Replaces Lusutrombopag – (P0080).
Nitisinone - (IP0146)
Parathyroid Hormone - (IP0177)
Pimavanserin - (IP0145)
Romiplostim - (IP0155)
  • Replaces Romiplostim – (9002).
Romosozumab - (IP0179) 		New
  • Supports pharmacy prior authorization requirements
Cerliponase Alfa - (IP0175)
  • Replaces Cerliponase Alfa – (1807).
Edaravone - (IP0176)
  • Replaces Edaravone - (1806).
Imiglucerase - (IP0162)
Repository Corticotropin - (IP0178)
  • Replaces Repository Corticotropin - (8001).
Taliglucerase - (IP0163)
Velaglucerase - (IP0164) 		New
  • Supports medical precertification requirements
Cabotegravir – (IP0124)
and
Cabotegravir-Rilpivirine – (IP0123)		 New
  • Important changes in coverage criteria:
    • Added requirement that individual must have difficulty maintaining compliance to daily antiretroviral therapy or have gastrointestinal issues that limit absorption or tolerance to oral agents.
Calcitonin Gene-Related Peptide (CGRP) Inhibitors – Preventative Migraine Treatment for Employer Group Plans - (IP0050) Modified
  • Minor changes in coverage criteria/policy:
    • Revised conditions not covered section to add no concurrent use with Nurtec ODT for preventative use.
COVID-19 Therapeutics – (2016) Modified
  • Important changes in coverage criteria:
    • Modified criteria following to be consistent with most recent emergency use authorization for:
      • baricitinib (Olumiant).
      • casirivimab-imdevimab (REGEN-COV).
Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List – (1601)
and
Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List – (1602)		 Modified
Enzyme Related Therapies – (1319) Modified
Immunomodulators (Individual and Family Plans) - (1903)
and
Immunomodulators – Oral and Subcutaneous (Standard/Performance, Value/Advantage, Legacy Drug List Plans) - (1805)
and
Immunomodulators – Oral and Subcutaneous (Cigna Total Savings Plan) - (2102)		 Modified
  • Important changes in coverage criteria:
  • Added Cosentyx expanded indication for treatment of pediatric plaque psoriasis.
  • Added new indication for Actemra subcutaneous for treatment of interstitial lung disease associated with systemic sclerosis (SSc-ILD).
Oncology Medications – (1403) Modified
  • Important changes in coverage criteria:
    • Added criteria for accepted off-label pediatric oncology use.
    • Added criteria for Sandostatin LAR Depot.
    • Added to pharmacy and/or medical tables:
      • Lumakras.
      • Rybrevant.
      • Sandostatin LAR Depot.
      • Truseltiq.
Ozanimod – (2022) Modified
  • Important changes in coverage criteria:
    • Added criteria for ulcerative colitis.
Pharmacy Prior Authorization – (1407) Modified
Rimegepant - (IP0147) Modified
  • Important changes in coverage criteria:
    • Added criteria for preventative treatment of episodic migraine.
Sublingual Allergen Immunotherapy – (1902) Modified
  • Important changes in coverage criteria:
    • Revised age for Ragwitek down to five years of age and older.
Avatrombopag - (P0079) Retired
Cerliponase Alfa – (1807) Retired
Cyanocobalamin nasal spray – (P0097) Retired
Edaravone - (1806) Retired
Eltrombopag - (9003) Retired
Fostamatinib - (P0081) Retired
Glycerol Phenylbutyrate - (P0113) Retired
Ibalizumab-uiyk – (M0001) Retired
Lusutrombopag - (P0080) Retired
Ocriplasmin – (1310) Retired
  • Discontinued to be manufactured in the United States.
Repository Corticotropin - (8001) Retired
Romiplostim - (9002) Retired
Epinephrine - (P0003)
and
Topical Corticosteroids (Rectal) - (IP0037)
and
Topical Vitamin D Analogs - (P0077)		 Retired
Policies Status Details
Precertification List – Commercial (Non-Medicare) Business*
  • No updates for August 2021.
Policies Status Details
Precertification List – Medicare Business*
Medicare - Master Precertification List Modified
  • Important changes, effective October 1, 2021:
    • Removing:
      • Eighty-two trauma and fracture codes.
      • HCPCS code 0019U.
      • Expired HCPCS “C” codes.
    • Adding:
      • HCPCS code 0037U.
      • Replacement HCPCS “J“ and “Q” codes for expired C codes.
Policies Status Details
Reimbursement Policies*
DRG Readmission – (R35)
Emergency Room Services – (R36) 		New
  • Two new reimbursement policies.
Policies Status Details
ClaimsXten*
  • No updates for August 2021.

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.