Policy Updates April 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective April 15, 2017:
Allergy Testing and Non-Pharmacologic Treatment - (0070) Modified
  • Important change in coverage criteria:
    • Added content on sublingual antigen extract drop immunotherapy preparations.
Benign Prostatic Hyperplasia (BPH) Treatments – (0159) Modified
  • Important change in coverage criteria:
    • Added coverage of prostatic urethral lift procedure/device.
External Insulin Pumps – (0087) Modified
  • Important change in coverage criteria:
    • Expanded existing coverage to include a subtype of type 2 diabetics.
Home Blood Glucose Monitors – (0106) Modified
  • Important change in coverage criteria:
    • Expanded existing coverage of minimally invasive continuous glucose monitoring system (CGMS).
Omnibus Codes – (0504) Modified
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy (drugs & biologics) coverage policies were modified effective April 15, 2017:
Immune Globulin Therapy - (5026) Modified
  • Important changes in coverage criteria:
    • Added subcutaneous immune globulin (SCIG) content from Immune Globulin Subcutaneous (Human) – (8004) coverage policy.
      • SGIC or IVIG covered for primary immunodeficiency.
      • Only IVIG is covered for all other conditions listed.
      • Immune Globulin Subcutaneous (Human) – (8004) will be retired.
    • Updated title to reflect combination of SCIG and IVIG.
  • Lanreotide for Non-Oncology Indications - (9005) Modified
    Mecasermin - (6107) Modified
    • Important changes in coverage criteria:
      • Added criteria specifying that use is in children two years of age or older.
      • Updated initial and reauthorization criteria that child is not currently treated for growth hormone deficiency (GHD).
      • Clarified genetic evidence criteria for growth hormone gene mutation with development of neutralizing antibodies to growth hormone.
      • Added that use in active or suspected neoplasia is experimental, investigational, or unproven (EIU).
      • Added that use in idiopathic short stature is considered not medically necessary.
      • Removed trade name from title.
    Octreotide for Non-Oncology Indications - (5015) Modified
    • Important change in coverage criteria:
      • Added coverage for pituitary adenoma producing thyroid stimulating hormone (TSH) when surgical resection has been incomplete.
        • Previously covered; removed in error during annual review in March.
    Oncology Medications - (1403) Modified
    • Important changes in coverage criteria:
      • Added Kisqali (ribociclib) to the pharmacy benefit table.
      • Added Somatuline Depot (lanreotide) to the medical benefit table.
    Step Therapy - (1109) Modified
    • Important changes in coverage criteria:
      • Added Adrenaclick, Auvi-Q®, EpiPen, and EpiPen Jr to the B / Emerging Step Drug List as Step 2 medications behind the authorized generic epinephrine auto-injector.
    Step Therapy Individual and Family Plans – (1603) Modified
    • Important changes in coverage criteria:
      • Updated criteria language used for Long Acting Narcotics – Non-Abuse Deterrent Formulations:
        • Changed from “Requires one Step 1 before Step 2 and one Step 2 before Step 3” to “Requires one Step 1 and one Step 2 before Step 3” to match intent of program.
    Transmucosal Fentanyl - (1018) Modified
    • Important changes in coverage criteria:
      • For Individual and Family Plans, specified that prior use of transmucosal fentanyl lozenge is the generic available for Actiq.
      • Removed trade names from title.
    Immune Globulin Subcutaneous - (8004) Retired
    Policies Status Details
    Administrative Policies
    Preventive Care Services – (A004) Modified
    • Important changes in coverage criteria:
      • Fall prevention services will be covered when submitted with:
        • R26.81 Unsteadiness on feet.
      • Fall prevention services will no longer be covered when submitted with:
        • W19.XXXS Unspecified fall, sequel
        • Z51.89 Encounter for other specified aftercare
        • Z72.3 Lack of physical exercise
        • Z72.9 Problem related to lifestyle, unspecified
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    Various Modified Eighteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
    *Please log in to view these policies.
    Policies Status Details
    Precertification Policies*
    Updates have been made to the following:
    Medical Oncology Drugs Requiring Precertification Modified
    Master Outpatient Precertification List Modified
    Policies Status Details
    Reimbursement Policies*
    Updates have been made to the following:
    Healthcare Common Procedure Coding System (HCPCS) National Level II Modifiers Modified
    R27 Related Services, Supplies, Drugs and Equipment New
    Policies Status Details
    Claim Editing Policies and Procedures* ClaimsXten
    No updates for April 2017.
    Policies Status Details
    Policies with a Reduction in Coverage
    There were no additional changes made in April 2017 that resulted in a reduction in coverage.

    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.