Policy Updates April 2016

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective April 15, 2016:
Balloon Sinus Ostial Dilation for Chronic Sinusitis - (0480) New
  • New coverage position – will be posted April 15, 2016 but is not effective until July 15, 2016.
  • This will provide advance health care professional notification.
    • Important change in coverage effective July 15, 2016:
      • Changed from covered to not covered for a subset of patients.
Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery - (0481) New
  • Policy statement update with no change in coverage:
    • All codes in this new coverage policy require precertification and are currently being denied.
Comparative Genomic Hybridization (CGH)/Chromosomal Microarray Analysis (CMA) for Autism Spectrum Disorders, Developmental Delay, Intellectual Disability and Multiple Congenital Anomalies - (0493) Modified
  • Updates will be posted on April 15, 2016, but are not effective until July 15, 2016.
  • This will provide advance health care professional notification.
    • Both versions will be available on the CPU page until July 15, 2016; one current and one with the July 15, 2016 effective date.
    • The current version should be used for all determinations before July 15, 2016.
  • Important change in coverage:
    • Added policy statement and supporting disclaimer requiring genetic counseling.
  • Policy statement update with no change in coverage:
    • Removed "or Unspecified" before "Congenital Anomalies" in title.
External Insulin Pumps - (0087) Modified
  • Important change in coverage:
    • Removed phrase "for at least six months prior to initiation of the insulin pump."
  • Policy statement updates with no change in coverage:
    • Removed criteria about ages for type 1 and type 2 diabetes.
      • The age issue will be driven by the U.S. Food and Drug Administration (FDA) indications for the devices with the added phrase "when used according to the FDA approved indications" in the introductory statement after each pump type.
    • Removed bullets under enhanced features because wizard and hyperglycemic alarms are now standard.
    • Other miscellaneous edits for clarity.
Genetic Testing for Cancer Susceptibility Syndromes - (0518) Modified
  • Some of the changes posted will begin on April 15, 2016, while some are not effective until July 15, 2016.
    • July changes are being posted now to provide advance health care professional notification.
    • Both versions will be available on the CPU page until July 15, 2016; one current and one with the July 15, 2016 effective date.
    • The current version should be used for all determinations before July 15, 2016.
  • Important change in coverage starting April 15, 2016:
    • Deleted the term "invasive" in reference to ovarian cancer for BRCA testing.
  • Important change in coverage starting July 15, 2016:
    • Added genetic counseling requirement for all indications in policy.
Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias - (0517) Modified
  • Changes will be posted on April 15, 2016 but are not effective until July 15, 2016
  • This will provide advance health care professional notification.
    • Both versions will be available on the CPU page until July 15, 2016; one current and one with the July 15, 2016 effective date.
    • The current version should be used for all determinations before July 15, 2016.
  • Important change in coverage:
    • Added policy statement and supporting disclaimer requiring genetic counseling.
    • Updated criteria for dilated cardiomyopathy:
      • Changed to reflect that targeted singe gene or multigene panel testing is medically necessary for a patient who is a candidate for an implantable or wearable cardioverter defibrillator.
Home Blood Glucose Monitors - (0106) Modified
  • Policy statement update with no change in coverage:
    • Removed criteria about ages for type 1 and type 2 diabetes.
      • The age issue will be driven by the added wording in the introductory statement "when used according to the U.S. Food and Drug Administration (FDA) approved indications" and the criteria for the diagnosis of type 1 and type 2 diabetes.
    • Clarified replacement language.
Injectable Fillers - (0511) Modified
  • Important change in coverage:
    • Removed requirement from policy statement that the individual "not be a surgical candidate."
  • Policy statement updates with no change in coverage:
    • Changed listing of covered substances to bullets.
    • Added ProlarynTM (another name for the Radiesse Voice products) to covered substances bullets.
    • Removed "other" to clarify filler versus bulking agents.
Otoplasty and External Ear Reconstruction - (0335) Modified
  • Important changes in coverage:
    • Removed criteria about hearing impairment, staged reconstruction, and need for hearing aid or cochlear device.
Total Ankle Arthroplasty/Replacement - (0285) Modified
  • Changes below were previously posted on January 15, 2016 to provide advance health care professional notification.
  • Changes are now effective starting April 15, 2016.
  • The previous version of the policy will be removed April 15, 2016.
  • Important changes in coverage:
    • Added a not covered policy statement for:
      • customized ankle replacement procedures,
      • preoperative imaging associated with customized ankle replacement procedures
Transcranial Magnetic Stimulation - (0383) Modified
  • Important change in coverage (previously posted and effective March 28, 2016):
    • Changed major depressive disorder from not covered to covered.
Treatment of Cutaneous and/or Deep Tissue Hemangioma, Port Wine Stain and Other Vascular Lesions - (0313) Modified
  • Important change in coverage:
    • Added coverage for port wine stain on head and/or neck area.
  • Policy statement update with no change in coverage:
    • Added bullet to clarify port wine stain on trunk and extremities.
Wheelchairs/ Power Operated Vehicles - (0030) Modified
  • Policy statement update with no change in coverage:
    • Added new code E1012 to the Power Tilt and/or Recline Seating System policy statement.
    • Added anterior power tilt (K0108) to the existing not covered items policy statement.
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective April 15, 2016:
Immune Globulin Intravenous (Human) (IVIG) - (5026) Modified
  • Important changes in coverage:
    • Under the specific antibody deficiency section:
      • Added additional immunological evaluation criteria about documentation of administration of Prevnar (PCV 7, PCV 13).
      • Removed criteria about inadequate responsiveness to pneumococcal conjugate vaccine (Prevnar 13®).
      • Revised recurrent infection criteria.
Immune Globulin Subcutaneous (Human) - (8004) Modified
  • Important changes in coverage:
    • Under the specific antibody deficiency section:
      • Added additional immunological evaluation criteria about documentation of administration of Prevnar (PCV 7, PCV 13).
      • Removed criteria about inadequate responsiveness to pneumococcal conjugate vaccine (Prevnar 13).
      • Revised recurrent infection criteria.
Pharmacy Prior Authorization - (1407) Modified
  • Important changes in coverage:
    • Added pyrimethamine (Daraprim®) and progesterone (Endometrin®).
Routine Immunizations - (9001) Modified
  • Important changes in coverage:
    • Consolidated criteria about covering routine immunizations as medically necessary from two separate statements into one statement.
    • Removed permissive use statement.
    • Updated benefit description to include the Patient Protection and Affordable Care Act (PPACA) statement.
Step Therapy - (1109) Modified
  • Important changes in coverage:
    • Added Vraylar (cariprazine) to Global Step Therapy under Atypical Antipsychotic Agents.
Policies Status Details
Administrative Policies
There were no administrative policy updates for April.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Fourteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
Policies Status Details
Reimbursement Policies*
There were no reimbursement policy updates for April.
Policies Status Details
Claim Editing Policies and Procedures ClaimsXten
To better align with the Centers for Medicare & Medicaid Services (CMS), Cigna is implementing a bundled status for CPT 97010, effective August 13, 2016.
Policies Status Details
Policies with a Reduction in Coverage**
Ambulance Services Reimbursement Policy (R18) Modified With this update, we will only reimburse non-emergency ambulance transportation when a hospital is the origin or destination of the service. As such, claims billed without a hospital modifier (H) will not be reimbursed. We will also not provide additional reimbursement for ancillary services during non-emergency ambulance transportation, including ambulance waiting time and mileage past the nearest hospital.

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.

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**The following policy updates, effective April 11, 2016, will result in a reduction of coverage.