Coverage Policies

 

Supporting Websites

In certain commercial markets, Cigna delegates utilization management of specific services, including chiropractic care, physical and occupational therapy and advanced radiology services. In these situations, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

• eviCore Guidelines
• ASH - American Specialty Health (Therapy & Related Services)
• Cigna State Specific Guideline (AL, AR, CO, CT, MA, WA)

Supporting Behavioral Websites

Evernorth Behavioral Health uses a suite of existing evidence-based criteria to support your clinical judgment and decision-making processes. Most recently, for mental health care, Evernorth adopted externally developed Level of Care Utilization System (LOCUS) criteria for ages 18+, and Child and Adolescent level of Care/Service Intensity Utilization System (CALOCUS-CASII) criteria for ages 6 to 17, in compliance with California Senate Bill 855. These criteria will be used to conduct mental health level of care medical necessity reviews for all commercial health plans in California, unless federal or state law require the use of other specifically identified clinical criteria.

In addition to the medical coverage policies listed above, the following resources are used to make medical necessity determinations.

Updated August 2022

• MCG Behavioral Health Guidelines¹
  Evernorth uses this criteria, developed by MCG Health^®, for guidance in conducting medical necessity reviews of mental health levels of care for all health plan business, unless contractual requirements, federal or state law require use of other clinical criteria.
• The ASAM Criteria^®
  Evernorth uses this criteria, developed by the American Society of Addiction Medicine, for guidance in conducting medical necessity reviews of substance use disorder levels of care for all health plan business, unless contractual requirements, federal or state law require use of other clinical criteria.
• LOCUS and CALOCUS-CASII Criteria
  Evernorth uses the following criteria in California for guidance in conducting medical necessity reviews of mental health levels of care for all health plan business, unless contractual requirements, federal or state law require use of other clinical criteria.
  • LOCUS
  • CALOCUS-CASII
• Evernorth Authorization and Billing Resource
  For information on billing practices and authorization requirements, visit Resources > Behavioral Resources > Doing Business with Evernorth > Authorization and Billing Resource.
• State and federal regulations and licensing standards²
  
  • If applicable, refer to your state’s guidance to conduct mental health and substance use disorder level of care medical necessity reviews for commercial health plan business.

¹ On November 27, 2020, we terminated use of our Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders and transitioned to the MCG Behavioral Health Guidelines referenced above. Our former Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders are available for regulatory and reference purposes. This documentation will also be used throughout the duration of cases that are submitted to Cigna prior to November 27, 2020. These cases include:

• Prior authorization requests
• Continued care requests/concurrent reviews
• Appeals where the Cigna document is used in initial determinations

² Evernorth complies with state specific laws, as written.

 

Additional Information

• The terms of an individual's particular coverage plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard coverage plans upon which these coverage policies are based. If these Coverage Policies are inconsistent with the terms of the individual's specific coverage plan, then the terms of the individual's specific coverage plan always control.
• Coverage determinations in each specific instance require consideration of:
  • the terms of the applicable coverage plan document in effect on the date of service
  • any applicable laws/regulations
  • any relevant collateral source materials, including coverage policies
  • the specific facts of the particular situation
• Medical technology is continuously evolving; our coverage policies are subject to change without prior notice. Additional coverage policies may be developed as needed or may be withdrawn from use. Additionally, some coverage plans administered by Cigna HealthCare, such as certain self-funded employer plans or governmental plans, may not use Cigna HealthCare coverage policies. Doctors and individuals should contact their Cigna HealthCare representative for specific coverage information.
• Cigna also uses other tools developed by third parties to assist in interpreting health coverage plan provisions, including MCG™ Care Guidelines (Copyright © 2017 MCG Health, LLC), 20th Edition, 2017.
• Behavioral medical necessity criteria information can be provided, if requested.