Policy Updates February 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 policy:
Diagnostic Microbe Testing for Sexually Transmitted Diseases (STDs) - (0530)
  • We will implement a new medical coverage policy, Diagnostic Microbe Testing for Sexually Transmitted Diseases (STDs) (0530), to review tests for medical necessity.
  • Please note that this policy does not affect STD testing that is covered as a preventive benefit when billed with a wellness diagnosis. Additionally, medical necessity review is not required when STD testing is for patients ages two and under, or when billed with a pregnancy diagnosis.
  • This policy is effective for dates of service beginning February 18, 2019.
National Correct Coding Initiatives (NCCI) for Facilities Reimbursement Policy - (R09)
  • We will expand the list in our current National Correct Coding Initiatives (NCCI) for Facilities Reimbursement Policy (R09) to include industry-standard column one and column two procedure-to-procedure (PTP) codes where at least one of the codes is for an evaluation and management (E&M) visit in an emergency room when billed with another service. We will deny either the E&M or the other service as not separately reimbursable.
  • This update affects claims from outpatient facilities processed on or after February 18, 2019.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective February 15, 2019:
Diagnostic Microbe Testing for Sexually Transmitted Diseases (STD) – (0530) New
  • Advance notification originally provided on November 15, 2018 for policy effective February 15, 2019:
    • Identifies medically necessary ICD10 codes/CPT code pairs for diagnostic microbe testing for:
      • Chlamydia
      • Gardnerella
      • Genital Herpes (Herpes Simplex Virus Types 1 and 2)
      • Gonorrhea (Neisseria gonorrhea)
      • Human Papillomavirus (HPV)
      • High-risk types (e.g., types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)
      • Invasive Candidiasis
      • Candidemia
      • Trichomonas
      • Syphilis
    • Reflects that molecular testing is not medically necessary for:
      • Noninvasive or mucosal candidiasis (e.g., vaginal candidiasis)
      • HPV
      • Low-risk types (e.g., types 6, 11, 42, 43, 44)
      • Syphilis
  • Includes reimbursement note that use of “not otherwise specified” codes is not reimbursable when a more specific code is available.
Breast Implant Removal - (0048) Modified
  • Important change in coverage criteria:
    • Added breast implant removal for diagnosed breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).
Breast Reconstruction Following Mastectomy or Lumpectomy - (0178) Modified
  • Important changes in coverage criteria:
    • Added four products to existing experimental, investigational or Unproven (EIU) policy statement:
      • ARTIA™ Reconstructive Tissue Matrix
      • BellaDerm® Acellular Hydrated Dermis
      • GalaFLEX® Surgical Scaffold/Mesh
      • GalaFORM™ 3D
    • Removed reference to “vascularized lymph node transfer (VLNTx)”.

Diabetes Equipment and Self-Management – (0106)

 Modified
  • Important changes in coverage criteria:
    • Changed title from “Home Blood Glucose Monitors to Diabetes Equipment and Self-Management”.
    • Combined information from the following three policies being retired:
      • Diabetes Self-Management – (0413)
      • Diabetic Supplies – (0126)
      • External Insulin Pumps – (0087)
    • Updated policy statement for glucose monitors and diabetes supplies:
      • differentiated between non-therapeutic and therapeutic continuous glucose monitors (CGMs) and updated language.
Drug Testing - (0513) Modified
  • Important changes in coverage criteria:
    • Deleted bullet about specimen verification:
    • Added note that specimen verification is part of the quality assurance process and not separately reimbursable.
Exhaled Nitric Oxide in the Management of Respiratory Disorders – (0439) Modified
  • Important changes in coverage criteria:
    • Changed title from “Exhaled Nitric Oxide and Exhaled Breath Condensate in the Management of Respiratory Disorders”.
    • Removed “Breath Condensate” wording from policy.
Omnibus Codes - (0504) Modified
  • Important changes in coverage criteria:
    • Reviewed non-FDA services - all remain EIU.
    • Added one EIU service that has recent FDA approval to the OB/GYN section:
      • Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency.
    • Added section for percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve).
      • Remains EIU.
Plantar Fasciitis Treatments - (0097) Modified
  • Important change in coverage criteria:
    • Removed acupuncture from existing EIU policy statement.
Tissue-Engineered Skin Substitutes - (0068) Modified
  • Important changes in coverage criteria:
    • Increased number of covered Grafix applications from four to six.
    • Added 36 new products added to existing EIU policy statement.
Biofeedback – (0166) Retired
Computerized Electrocardiograph (ECG) Analysis – (0210) Retired
  • Being retired on February 19, 2019.
Mechanical Devices for the Treatment of Back Pain – (0140) Retired
Pulsed Electromagnetic Therapy – (0236) Retired
  • Being retired on February 19, 2019
Three policies being retired with content added to Diabetes Equipment and Self-Management – (0106) Retired
  • Diabetes Self-Management – (0413)
  • Diabetic Supplies – (0126)
  • External Insulin Pumps – (0087)
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Biofeedback – (CPG 294) New
  • Added content from retired medical coverage policy Biofeedback – (0166).
  • Additional covered conditions include fecal incontinence, stroke, and refractory levator ani syndrome.
Home Traction Devices – Cervical and Lumbar – (CPG 265) Modified
  • Important changes:
    • Added gravity-assisted traction from retired medical coverage policy Mechanical Devices for the Treatment of Back Pain – (0140).
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Updated Cigna-eviCore Cobranded High-Tech Radiology Therapy Guidelines for breast imaging effective January 29, 2019: Modified
  • Added computer-aided detection (CAD) for breast magnetic resonance imaging (MRI).
    • Remains EIU.
Updated the following Comprehensive Musculoskeletal Management guidelines: Modified
Policies Status Details
Administrative Policies
  • No updates for February 2019.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following drug and biologic coverage policies were modified effective March 1, 2019:
Avatrombopag – (P0079) New
  • Supports pharmacy prior authorization.
Fostamatinib – (P0081) New
  • Supports pharmacy prior authorization.
Hereditary Transthyretin Amyloidosis Agents – (1901) New
  • Supports medical precertification for Onpattro (patisiran).
  • Supports pharmacy prior authorization for Tegsedi (inotersen).
Ibalizumab-uiyk – (M0001) New
  • Supports medical precertification.
Lusutrombopag – (P0080) New
  • Supports pharmacy prior authorization.
Cerliponase alfa – (1807) Modified
  • Important changes in coverage criteria:
    • Modified genetic testing with specific “biallelic pathogenic or likely pathogenic variants in the TPP1 gene”.
    • Modified the medically necessary statement to include that the individual be symptomatic.
Denosumab – (1212) Modified
  • Important changes in coverage criteria:
    • Added criteria for treatment of glucocorticoid-induced osteoporosis.
    • Modified criteria for treatment of giant cell tumor of bone for Xgeva.
    • Added concomitant use with bisphosphonate as an EIU use.
    • Added thalassemia-induced osteoporosis as an EIU use in those individuals who do not meet the osteoporosis coverage.
    • Added initial authorization up to 12 months.
Dimercaprol and Edetate Calcium Disodium – (6019) Modified
  • Important changes in coverage criteria:
    • Expanded the EIU statement to add other heavy metal poisoning.
Hepatitis C Therapy - (1316) Modified
  • Important changes in coverage criteria:
    • Added authorized generics as preferred products for Employer Groups.
      • Brand products remain preferred products for Individual and Family Plans.
Implantable Hormone Pellets – (1504) Modified
  • Important changes in coverage criteria:
    • Modified laboratory values that define low testosterone levels.
    • Added a “male” bullet for hypogonadism/hypogonadotropic hypogonadism and delay in puberty criteria for Testopel (testosterone pellets).
    • Revised the EIU section by removing the treatment of menopausal symptoms for Testopel and adding use in females for any indication.
    • Added reauthorization criteria:
      • Must have met all criteria for initial therapy and documentation of “positive clinical response”.
Modafinil/Armodafinil - (1501) Modified
  • Important changes in coverage criteria:
    • Added age restriction aligned to the FDA label of both products.
    • Streamlined the obstructive sleep apnea/hypopnea syndrome indication statement.
    • Streamlined the Parkinson's disease excessive daytime sleepiness (EDS), without changing the criteria intent.
    • Added initial and reauthorization criteria.

Oncology Medications – (1403)

 Modified
  • Important change in coverage criteria:
    • Added Khapzory to specific additional criteria table.
Oral Phosphodiesterase-5 (PDE5) Inhibitors - (7003) Modified
  • Important change in coverage criteria:
    • Updated criteria stem to reflect new Staxyn generic.
Repository Corticotropin - (8001) Modified
  • Important changes in coverage criteria:
    • Added statement incorporating updated version of the less costly alternative language found in the background:
      • No change to criteria intent.
    • Added initial and reauthorization criteria.
Step Therapy (Global) - (1109) Modified
  • Important changes in coverage criteria:
    • Removed Belbuca.

Step Therapy - Standard and Performance PDLs (Employer Group Plans) - (1801) and Step Therapy - Value and Advantage PDLs (Employer Group Plans) - (1802) and Step Therapy - Legacy Group Plan (Employer Group Plans) - (1803)

Modified
  • Important changes in coverage criteria:
    • Added new strength (160 mg) of nanocrystallized fenobfibrate to Fibrates - Standard Dose Step 1 list.
Tasimelteon - (P0018) Modified
  • Important changes in coverage criteria:
    • Added age restriction aligned to the inclusion criteria from pivotal trials (SET and RESET).
    • Added initial and reauthorization criteria.
Quantity Limitations - (1201) Modified
  • Important changes in coverage criteria:
    • Added quantity limits for oral PDE5 inhibitors for Individual and Family Precription Drug Plan benefit reference.
    • Added budesonide (Uceris).
Policies Status Details
CareAllies Medical Necessity Guidelines
  • One policy updated for February 2019.
Policies Status Details
Precertification Policies*
  • No updates for February 2019.
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
Code Edit Bulletin (March 2019)
  • Important changes effective March 17, 2019:
    • To better align with CMS, Cigna is implementing Medically Unlikely Edits (MUE) for CPT codes 88300-88309, 90791-90792 and 90832-90839.

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.