Policy Updates April 2018

Important New 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 Details
Policies with a Reduction in Coverage
We are changing how we reimburse for the following policies for claims on or after April 15, 2018.

Obstructive Sleep Apnea (OSA) Treatment Services (0158)

  • We will update our coverage policy and only reimburse claims billed with E0485 or E0486 for OSA following a sleep study. Claims submitted with any diagnosis other than OSA will be denied. This update is effective for dates of service on or after April 15, 2018.

Pharmacy and Infusion Services (R14)

  • We will deny claims billed with HCPCS code J1642 for a heparin lock flush as not separately reimbursable. This update is effective for claims processed on or after April 15, 2018.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective April 15, 2018:
Transcatheter Ablation for the Treatment of Supraventricular Tachycardia (SVT) – (0529) New
  • Advance notification on April 1, 2018, of new policy effective July 1, 2018:
    • Addresses transcatheter ablation for the treatment of supraventricular tachycardia in adults.
    • Adding CPT code 93653 to precert.
Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery - (0481) Modified
  • Important change in coverage criteria:
    • Added new device, Sinuva, to existing not covered policy statement.
      • No change in coverage.

Home Blood Glucose Monitors - (0106)

Modified
  • Important changes in coverage criteria:
    • Updated types of continuous glucose monitors and associated coding.
      • No change in coverage.
Treatment of Gender Dysphoria – (0266) Modified
  • Important changes in coverage criteria:
Policies Status Details
Cigna-ASH Coverage Policy Guidelines
  • No updates for April 2018.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Policies Status Details
Administrative Policies
Preventive Care Services-(A004) Modified
  • Updated screening services and coding table:
    • Added blood pressure measurement for preeclampsia screening.
    • Abnormal blood glucose and type 2 diabetes screening and counseling:
      • Added HCPCS codes G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9800, G9881, G9882, G9883, G9884, G9885, and G9890.
    • Vaccines:
      • Added CPT codes 90660 and 90672:
        • Effective for dates of service on or after July 1, 2018.
      • Added CPT code 90739.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective April 15, 2018:
Antiemetic Therapy - (1705) Modified
  • Important changes in coverage criteria:
    • Modified criteria for the NK1 antagonists:
      • Emend (oral and IV)
      • Varubi (oral and IV)
      • Cinvanti (new IV aprepitant)
    • Added “combined with a 5-HT3 receptor antagonist” to criteria for the NK1 antagonists.
Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List - (1601) Modified
  • Important changes in coverage criteria:
    • Added criteria for Duzallo®.
    • Revised criteria for Treximet to add requirement of intolerance to generic Treximet.
    • Revised criteria for Trulance to add criteria for Irritable Bowel Syndrome with constipation.
Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List - (1602) Modified
  • Important changes in coverage criteria:
    • Added criteria for Duzallo and QTERN.
    • Revised criteria for Treximet to add requirement of intolerance to generic Treximet.
    • Revised criteria for Trulance to add criteria for Irritable Bowel Syndrome with constipation.
    • Revised criteria for Spiriva to separate criteria for COPD versus for asthma.
Lanreotide for Non-Oncology Indications - (9005) and Plerixafor - (9008) and Transmucosal Fentanyl - (1018) Modified
  • Important changes in coverage criteria:
    • Added specific uses considered experimental, investigational, or unproven (EIU).
Pharmacy Prior Authorization - (1407) Modified
  • Important changes in coverage criteria:
    • Added criteria for Duzallo and Noctiva.
Step Therapy – (1109) and Step Therapy – Standard Prescription Drug Lists (Employer Group Plans) (1801) and Step Therapy – Value Prescription Drug Lists (Employer Group Plans) (1802) and Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) (1803) Modified
  • Important changes in coverage criteria:
    • Added Step Therapy for Trelegy Ellipta and Impoyz
Policies Status Details
CareAllies Medical Necessity Guidelines
One policy has been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
Policies Status Details
Precertification Policies*
  • We have updated the Master Precertification List
    • Important changes:
      • Added 13 additional HCPCS/CPT codes to precertification, effective April 1, 2018:
        • C9463, C9464, C9465, C9466, C9467, C9468, C9469, C9749, A9699, 0036U, 0037U, 0012M and 0013M; which includes:
          • Several drug codes added to the eviCore medical oncology program.
          • A couple of PLA (Proprietary Laboratory Analyses) and MAAA codes (Multianalyte Assays Algorithmic Analyses) codes.
Policies Status Details
Reimbursement Policies*
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
Code Edit and Policy Guidelines
  • Improtant changes:
    • On May 19, 2018, ClaimsXten will be updated to Second Quarter Knowledge Base content and NCCI Version 24.1 for all medical and behavioral claims.

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.