Policy Updates March 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
We are changing how we reimburse for the following policies:
Airway Clearance Devices in the Ambulatory Setting – (0069)
  • We will update the way we process claims for airway clearance devices billed with Healthcare Common Procedure Coding System (HCPCS) code E0482 (cough stimulating device).
  • We will edit claims submitted with this code to ensure a medically appropriate diagnosis code has been billed, and deny coverage if it is not considered medically necessary.
  • This update will be effective for claims with dates of service on or after March 15, 2021.
  • This update will affect the following medical coverage policy: Airway Clearance Devices in the Ambulatory Setting – (0069).
Chiropractic Care – (CPG278)
Physical Therapy – (CPG135)
Occupational Therapy – (CPG155)
  • We will update the way we process claims for physical therapy services billed with Current Procedural Terminology (CPT®) codes 97016 (vasopneumatic device) and 97026 (infrared therapy).
  • We will deny coverage of these codes as not medically necessary for dates of service on or after March 15, 2021.
  • This update will affect the following medical coverage policies:
    • Chiropractic Care – CPG 278
    • Physical Therapy – CPG 135
    • Occupational Therapy – CPG 155
Rhinoplasty, Vestibular Stenosis Repair and Septoplasty - (0119)
  • We will deny coverage for septoplasty procedures billed with Current Procedural Terminology (CPT®) code 30520 that do not meet medical necessity criteria.
  • This update aligns with our existing medical coverage policy, Rhinoplasty, Vestibular Stenosis Repair and Septoplasty (0119).
  • This update is effective for claims with dates of service on or after March 15, 2021.
Policies Status Details
Medical Coverage Policies
  • Unless otherwise noted, the following medical coverage policies were modified effective March 15, 2021:
Site of Care: Outpatient Hospital for Select Musculoskeletal Procedures – (0553) New
  • Originally provided advance notification on September 15, 2020, of new policy effective April 2, 2021:
    • eviCore to redirect inpatient musculoskeletal services to outpatient sites.
Ambulatory Electrocardiographic Monitoring – (0547)) Modified
  • Advance notification of of important changes in coverage criteria effective May 15, 2021:
    • Updated title from “Ambulatory Electrocardiographic Monitoring” to current title.
    • Expanded coverage to include external event monitors and mobile cardiac outpatient monitoring.
    • Added policy statement to address replacement of implantable electrocardiographic event monitors.
    • Added policy statement for self-monitoring devices and software.
Infertility Services – (0089) Modified
  • Important changes in coverage criteria:
    • Removed “semen analysis” and “Krugers strict criteria” from male infertility treatment section.
Miscellaneous Musculoskeletal Procedures – (0515) Modified
  • Important changes in coverage criteria:
    • Added policy statement for acellular collagen matrix used for articular cartilage repair.
Omnibus Codes – (0504) Modified
Percutaneous Revascularization of the Lower Extremities in Adults – (0537) Modified
  • Important changes in coverage criteria:
    • Expanded coverage of “stenosis of 50%-75%” to “stenosis of greater than 50%”.
    • Clarified criteria claudication due to profunda femoral artery disease.
    • Added policy statement addressing intravascular lithotripsy:
      • HCPCS codes C9764 - C9767 and C9772 - C9775.
Peripheral Nerve Destruction for Pain Conditions – (0525) Modified
  • Important changes in coverage criteria:
    • Added additional criteria of hip pain and shoulder pain.
Rhinoplasty, Vestibular Stenosis Repair and Septoplasty - (0119) Modified
  • Originally provided advance notification of important changes in coverage criteria on December 15, 2020, effective March 15 2021:
    • Updated coding for septoplasty.
    • Added diagnosis codes to be implemented with a procedure-to-diagnosis (PXDX) edit for CPT code 30520.
      • No change to existing policy statement.
Site of Care: High-tech Radiology – (0550) Modified
  • Important changes in coverage criteria, effective February 22, 2021:
    • Updated age criteria.
Treatment of Gender Dysphoria – (0266) Modified
  • Important changes in coverage criteria:
    • Added coverage of breast augmentation, pectoral implants, scrotoplasty, and testicular prosthesis-related procedures.
    • Added language to clarify procedures are reviewed on a case-by-case basis.
    • Updated policy statement that addresses age 18 years or older.
    • Removed reference to fertility preservation/cryopreservation procedures.
Injectable Bulking Agents for Urinary Conditions and Fecal Incontinence – (0206) Retired
  • Retired effective March 26, 2021.
Ventilator Weaning – (0432) Retired
  • Retired effective March 15, 2021.
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Chiropractic Care – (CPG278) Modified
  • Originally provided advance notification of important changes on December 15, 2021, effective March 15, 2021
Physical Therapy – (CPG 135) Modified
  • Originally provided advance notification of important changes on December 15, 2021, effective March 15, 2021
Occupational Therapy – (CPG 155) Modified
  • Originally provided advance notification of important changes on December 15, 2021, effective March 15, 2021
  • Updated to note the application of infrared and vasopneumatic device is considered not medically necessary.
    • CPT codes 97016 and 97026.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
High-Tech Radiology (HTR or Imaging) guidelines
  • Originally provided advance notification on January 1, 2021, of revisions effective April 1, 2021.
    • Pelvis, General
Comprehensive Musculoskeletal Management (CMM) guidelines
  • Advance notification of important changes, effective July 1, 2021:
    • Posting on Cigna-eviCore cobranded guideline home page.
    • Formatting/editing changes to all guidelines for National Committee for Quality Assurance (NCQA) purposes.
Policies Status Details
Administrative Policies
Preventive Care Services - (A004) Modified
  • Important changes, effective March 1, 2021:
    • Screening for Hepatitis C:
      • Changed from adults at risk for infection (one time screening for adults born between 1945 and 1965) to all adults aged 18-79.
      • Added allowed with maternity diagnosis.
    • Breast Feeding equipment and High Blood Pressure equipment:
      • Removed reference to CareCentrix, leaving eviCore as durable medical equipment (DME) vendor.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective March 1, 2021:
Cysteamine Ophthalmic Solution - (IP0082)
Metoclopramide Nasal Spray – (IP0085)
Sarecycline - (IP0093)		 New
  • Supports pharmacy prior authorization requirements
Setmelanotide for Employer Group Plans – (IP0104) New
  • Supports pharmacy prior authorization requirements
  • Effective date March 15, 2021.
Solriamfetol – (IP0102) New
  • Supports pharmacy prior authorization requirements
  • Effective date March 15, 2021.
  • Replaces Solriamfetol – (P0106).
Inhaled Antibiotic Therapy – (IP0094) New
  • Supports pharmacy prior authorization of inhaled antibiotic therapy, including:
    • Aztreonam (Cayston)
    • Tobramycin (Bethkis, Kitabis, Tobi, Tobi Podhaler and generics).
Oxybate – (IP0103) New
  • Effective date March 15, 2021:
    • Supports pharmacy prior authorization of:
      • Xyrem® (sodium oxybate)
      • Xywav™ (calcium, magnesium, potassium, and sodium oxybates).
      • Replaces Sodium Oxybate – (P0075).
Lumasiran - (IP0095) New
  • Supports medical precertification requirements.
COVID-19 Drug and Biologic Therapeutics - (2016) Modified
  • Important changes in coverage criteria:
    • Added criteria for Bamlanivimab and Etesevimab.
COVID-19 Vaccine- (2029) Modified
  • Important changes in coverage criteria, effective Febraury 27, 2021:
    • Added Janssen COVID-19 vaccine/codes to list of emergency use authorized vaccines.
Insulin glargine - (P0023) Modified
  • Important changes in coverage criteria:
    • Added criteria for Semglee (insulin glargine U-100).
Pitolisant – (P0111) Modified
  • Important changes in coverage criteria, effective March 15, 2021:
    • Added criteria for Cataplexy associated with Narcolepsy.
    • Clarified criteria for sleep study requirements (mean sleep latency test and polysomnogram).
    • Removed combination of stimulant medications from the experimental, investigational or unproven (EIU) section.
Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use – (1206) Modified
  • Important changes in coverage criteria:
    • Added criteria for other neovascular diseases of the eye, such as:
      • Neovascular glaucoma.
      • Retinopathy of prematurity.
      • Sickle cell neovascularization.
      • Choroidal neovascular conditions.
Inhaled Antibiotic Therapy – (P0102) Retired
Sacubitril/Valsartan - (P0016) Retired
  • No longer subject to prior authorization on Employer Group or Individual and Family prescription drugs lists.
Sarecycline – (P0092) Retired
Sodium Oxybate – (P0075) Retired
Solriamfetol – (P0106) Retired
Step Therapy - (1109) Retired
  • Employer group plans no longer use this step therapy program.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for March 2021.
Policies Status Details
Precertification Policies*
  • No updates for March 2021.
Policies Status Details
Reimbursement Policies*
  • Unless otherwise noted, the following medical coverage policies were modified effective March 15, 2021:
Policies Status Details
ClaimsXten*
  • No updates for March 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.