Policy Updates April 2019

Important 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 Update to Coverage
Policies With a Reduction in Coverage
We are changing how we reimburse for the following policy:

Peripheral Angioplasty

Percutaneous Revascularization of the Lower Extremities in Adults - (0537)

  • We will implement a new medical coverage policy, Percutaneous Revascularization of the Lower Extremities in Adults - (0537), to review peripheral angioplasty procedures for medical necessity.
  • This policy is effective for dates of service beginning April 1, 2019.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective April 15, 2019:
Duplex Scan to Evaluate for Carotid Artery Stenosis – (0542) New
  • Advance notification of policy posting April 18, 2019; effective July 15, 2019
Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation – (0480) Modified
  • Important changes in coverage criteria:
    • Expanded scope to include Eustachian tube dilation as experimental, investigational and unproven (EIU).
    • Updated title from Balloon Sinus Ostial Dilation for Chronic Sinusitis.
Otoplasty and External Ear Reconstruction - (0335) Modified
  • Important change in coverage criteria:
    • Removed incisionless otoplasty statement.

Pneumatic Compression Devices and Compression Garments - (0354)

Modified
  • Advance notification of important changes in coverage criteria, effective July 15, 2019:
    • Removed from covered diagnosis list:
      • ICD10 code I87.1 (compression of vein).
        • Will be not covered for use with pneumatic compression device.
      • HCPCS code E0676 (Intermittent limb compression device [includes all accessories])
Scar Revision - (0328) Modified
  • Important change in coverage criteria:
    • Added statement addressing silicone combination kit as not medically necessary (NMN).
Treatment of Gender Dysphoria - (0266) Modified
  • Important changes in coverage criteria:
    • Expanded coverage to include electrolysis of donor site tissue for vaginoplasty or phalloplasty.
Wheelchairs/Power-Operated Vehicles - (0030) Modified
  • Important changes in coverage criteria:
    • Added physical therapy (PT)/occupational therapy (OT) evaluation for configuration of ultralight wheelchair.
    • Removed age-related language restriction for customized pediatric stroller.
    • Moved the manual tilt-in-space wheelchair from the Power Tilt and/or Recline Seating System section to the Manual Specialized Wheelchair section.
      • Added PT/OT evaluation for configuration of the chair.
    • Added language to allow use of the feature for the individual to participate in activities of daily living in school and/or employment for the Push-Rim Activated Power Assist Device.
    • Added “manage increased tone and spasticity” for a fully reclining back option.
    • Added adjustable manual height booster base seating system to existing NMN policy statement.
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • No new or updated policies for April 2019.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Advance notification of updates to the following Cigna-eviCore Cobranded Radiation Therapy guidelines, effective July 1, 2019: Modified
  • Proton Beam Therapy:
    • Divided policy statement into three groups:
      • Covered
      • NMN
      • EIU
    • Added coverage for intrahepatic cholangiocarcinoma and craniospinal irradiation.
    • Added eight new indications to the NMN list of conditions:
      • Primary central nervous system (CNS) cancer
      • Remaining cases of unresectable hepatocellular carcinoma and intrahepatic cholangiocarcinoma
      • Hodgkin’s Lymphoma
      • Non-Hodgkin’s Lymphoma
      • Stage IIIB Non-Small Cell Lung Cancer
      • Pancreatic cancer
      • Retroperitoneal Sarcoma
      • Thymomas and Thymic Carcinoma
    • Changed combination of photon and proton delivered in a stereotactic manner from EIU to covered.
    • Changed proton beam delivered in a stereotactic manner from EIU to covered.
  • Radiation Therapy for Prostate Cancer
    • Removed coverage statement for stereotactic body radiation therapy (SBRT) for high-risk prostate cancer:
      • Based on recently published American Society of Clinical Oncology (ASCO) guideline and policy.
  • Radiation Treatment with Lutathera (Lutetium; Lu 177 dotatate)
    • Added coverage for inoperable or metastatic somatostatin receptor positive bronchopulmonary thymic tumors in adults:
      • Based on evidence and National Comprehensive Cancer Network (NCCN) guideline.
  • Selective Internal Radiation Therapy
    • Added coverage for “Unresectable metastatic liver tumors from other primary malignancies, including breast carcinoma, ocular melanoma, cutaneous melanoma, and intrahepatic cholangiocarcinoma, in the absence of available systemic or liver-directed treatment options for relief of symptoms”:
      • Based on literature and NCCN guideline.
Policies Status Details
Administrative Policies
  • No updates for April 2019.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective April 1, 2019:
Butalbital Combination Products – (P0066) New
Skeletal Muscle Relaxants – (P0071) New
Sublingual Allergen Immunotherapy - (1902) New
  • Supports expanded coverage of oral sublingual allergen immunotherapy tablets.
  • Supports coverage and prior authorization with quantity limit for Grastek, Odactra, Oralair, and Ragwitek.
Triptorelin Pamoate – (M0009) New
  • Supports medical precertification.
Zolpidem - (P0069) New
Alpha1-Proteinase Inhibitor - (4037) Modified
  • Important changes in coverage criteria:
    • Revised wording for antitrypsin deficiency lung disease due to 2003 American Thoracic Society and the European Respiratory Society (ATS/ERS) issued standards.
    • Added age 18 years of age and older.
    • Added genotyping requirements to alpha1-antitrypsin (AAT) concentration level for documentation of diagnosis due to 2003 ATS/ERS issued standards.
    • Added up to 12 month initial authorization and reauthorization timeframe.
    • Added link to Genetic Testing for Hereditary and Multifactorial Conditions – (0052).
Antimigraine Preparations - (P0058) Modified
  • Important changes in coverage criteria:
    • Removed the step through Onzetra from the Imitrex nasal spray criteria.
    • Added new Onzetra criteria, effective July 1, 2019.
    • Removed Sumavel DosePro:
      • Product discontinued.
Calcitonin Gene-Related Peptide Inhibitors - (1813) Modified
  • Important changes in coverage criteria, effective March 21, 2019:
    • Removed separate onabotulinumtoxinA (Botox) requirement:
      • Added as prophylactic option for preferred products.
    • Added requirement to step through Aimovig, for non-preferred products (Ajovy and Emgality) on the Value/Advantage formulary.
    • Moved the Botox EIU statement to a medical necessity criteria statement.
Clotting Factors and Antithrombin – (8007) Modified
  • Important changes in coverage criteria:
    • Added Jivi product and criteria.
    • Clarified reauthorization language statement:
      • Continuation of use is contingent on initial authorization criteria continuing to be met.
      • No change to intent.
    • Added initial authorization and reauthorization intervals.
      • No change to intent.
Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List – (1601) and 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 Nocdurna medical necessity criteria.
    • Removed Flovent Diskus/HFA:
      • Will be a preferred brand, effective April 1, 2019.
    • Updated medical necessity criteria for Aerospan, Alvesco, Armonair Respiclick, Arnuity Ellipta, Asmanex HFA, and Pulmicort Flexhaler (Value/Advantage only) to include Flovent Diskus/HFA as a covered alternative.
    • Added Advair Diskus medical necessity criteria.
    • Updated medical necessity criteria for Dulera and AirDuo Respiclick to remove brand Advair Diskus as covered alternative, effective May 1, 2019.
    • Updated Solodyn criteria:
      • New generic available.
    • Removed the following products - criteria now located in separate policies:
Flibanserin – (P0002) Modified
  • Important changes in coverage criteria:
    • Added initial authorization period of up to three months.
    • Added re-authorization period of up to 12 months, with criteria of having to meet initial criteria plus have documented positive clinical response and continue to be premenopausal.
      • Both changes supported by FDA label.
Histrelin acetate subcutaneous implant - (8008) Modified
  • Important changes in coverage criteria:
    • Updated title from Histrelin acetate subcutaneous implant (Supprelin® LA).
    • Added authorization durations and reauthorization criteria of once every 12 months:
      • Aligns with dosing frequency of histrelin acetate subcutaneous implant.
Interferon gamma-1b - (P0001) Modified
  • Important changes in coverage criteria:
    • Added note at beginning of criteria stem stating the oncology uses of interferon gamma-1b are not addressed.
    • Updated language for malignant osteopetrosis - adding the word severe.
      • Now reads as severe malignant osteopetrosis, which is the FDA labeled indication.
    • Added statement that initial and re-authorization periods are for up to 12 months.
Interferon Therapy – (1315) Modified
  • Important changes in coverage criteria:
    • Removed language requiring use with a therapeutic alternative before interferon alpha therapy for polycythemia vera (PV) and essential thrombocythemia uses (ET).
      • Change made because these conditions are uncommon and interferon therapy is associated with many side effects; there’s no concern for the misuse of interferon therapy present.
    • Clarified reauthorization language:
      • Continuation of use is contingent on initial authorization criteria continuing to be met.
      • No change to intent.
    • Added initial authorization and reauthorization intervals.
      • No change to intent.
Medication Administration Site of Care - (1605) Modified
  • Important changes in coverage criteria:
    • Added to the covered drugs table to support potential redirection of site of care and provide transparency and clarity:
      • Crysvita
      • Fasenra
      • Fulphila
      • Gamifant
      • Ilumya
      • Kanuma
      • Mepsevii
      • Mircera
      • Onpattro
      • Panzyga
      • Retacrit
      • Signifor LAR
      • Trogarzo
      • Udenyca
      • Ultomiris
Nonsteroidal Anti-inflammatory Drugs - (P0057) Modified
Omalizumab - (4026) Modified
  • Important changes in coverage criteria:
    • Allergen-related asthma:
      • Removed upper limit of IgE laboratory data level due to the 2018 Global Initiative for Asthma.
      • Added documented evidence of continued beneficial clinical response and clinical condition met the initial criteria to the reauthorization criteria.
    • Chronic idiopathic urticarial:
      • Reworded six week requirement to mirror language used in the joint 2018 guidelines by the European Academy of Allergy and Clinical Immunology, the Global Allergy and Asthma European Network, the European Dermatology Forum, and the World Allergy Organization for the definition, classification, diagnosis, and management of urticaria.
      • Removed requirement for hydroxyzine or doxepin and specified second generation H1 antihistamine at least at twice recommended dosing due to recommendations from joint 2018 guidelines by the European Academy of Allergy and Clinical Immunology, the Global Allergy and Asthma European Network, the European Dermatology Forum, and the World Allergy Organization.
      • Removed requirement for leukotriene receptor antagonist due to these agents not being recommended by joint 2018 guidelines by the European Academy of Allergy and Clinical Immunology, the Global Allergy and Asthma European Network, the European Dermatology Forum, and the World Allergy Organization
    • General:
      • Added drugs not to be used concomitantly with Xolair:
        • benralizumab (Fasenra)
        • dupilumab (Dupixent)
        • reslizumab (Cinqair).
      • Removed requirement to decrease the dose or discontinuation from the continued use criteria due to lack of specific guideline support (2018 guidelines by the European Academy of Allergy and Clinical Immunology, the Global Allergy and Asthma European Network, the European Dermatology Forum, and the World Allergy Organization for the definition, classification, diagnosis, and management of urticarial) and FDA prescriber information labeling.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Added specific criteria requiring a step therapy requirement for either Ibrance or Verzenio first, effective July 1, 2019, for the cyclin-dependent kinase (CDK) inhibitors.
    • Added an NMN statement to the coverage criteria stem for Lartruvo (olaratumab) based on updated clinical information.
    • Updated medical benefit table:
      • Added Mvasi (bevacizumab-awwb).
      • Removed Lartruvo (olaratumab).
Pharmacy Prior Authorization - (1407) Modified
  • Important change in coverage criteria:
    • Added Nocdurna criteria:
      • Supports prior authorization for Employer Group Legacy Prescription Drug Lists.
Step Therapy - (1109) Modified
  • Important changes in coverage criteria:
    • Removed Latuda and Ranexa from Step Therapy, effective April 1, 2019.
      • Added both as preferred brand.
Step Therapy - Standard/Performance Prescription Drug Lists (Employer Group Plans) - (1801) and Step Therapy – Value/Advantage Prescription Drug Lists (Employer Group Plans) - (1802) and Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803) Modified
Topical Acne - (P0049) Modified
  • Important change in coverage criteria:
    • Incorporated Clindagel and aligned to current acne therapy criteria.
Voriconazole – (4004) Modified
  • Important changes in coverage criteria:
    • Added statement clarifying the use of oral voriconazole, and that IV formulation is not addressed.
    • Revised criteria stem language to align with format standard; minor edit to therapeutic alternatives language in use for HIV-infected adults and adolescents changing “and” to “or” due to bioavailability variability with, and between, itraconazole formulations.
    • Clarified reauthorization language:
      • Continuation of use is contingent on initial authorization criteria continuing to be met.
      • No change to intent.
    • Added initial authorization and reauthorization intervals.
      • No change to intent.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for April 2019.
Policies Status Details
Precertification Policies*
  • No updates for April 2019.
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
Code Editing Policy & Guidelines
  • On May 18, 2019, ClaimsXten will be updated to Second Quarter Knowledge Base content and NCCI Version 25.1 for all medical and behavioral claims we process.

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.