Policy Updates August 2016

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective August 15, 2016:
Atherosclerotic Cardiovascular Disease Risk Assessment: Emerging Laboratory Evaluations - (0137) Modified
  • Policy statement update with no change in coverage:
  • Policy statement updates - unknown if change in coverage:
    • Added the following to the existing not covered policy statement:
      • Coenzyme Q10
      • Molecular lipid and metabolic profiling
      • sPLA2
      • Skin cholesterol testing
      • Three additional test panels
      • Troponin for screening
Complementary and Alternative Medicine – (0086) Modified
  • Policy statement update - unknown if change in coverage:
    • Added magnetic resonance therapy to the existing not covered policy statement.
Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis – (0514) Modified
  • Important change in coverage:
    • Updated existing coverage policy statement of sequencing-based non-invasive prenatal testing (NIPT) to include testing for a viable gestation pregnancy ≥10 week’s gestation.
  • Policy statement updates with no change in coverage:
    • Updated not covered policy statement:
      • Made editorial changes about in- and out-of-network laboratory services.
    • Updated existing list of not covered prenatal testing:
      • Added whole genome NIPT
      • Added “when used to determine genetic cause of miscarriage (e.g., missed abortion, incomplete abortion)”.
Prophylactic Mastectomy - (0029) Modified
  • Policy statement updates with no change in coverage:
    • Added co-requirement of “two or more relatives with breast, pancreatic or prostate cancer (Gleason score ≥7) at any age” to existing coverage policy statement for personal history of pancreatic or prostate cancer.
    • Removed “invasive” as a descriptor for ovarian cancer from all policy statements.
Stem-Cell Transplantation for Autoimmune Diseases/Miscellaneous Conditions – (0357) Modified
  • Policy statement updates with no change in coverage:
    • Changed title – added “Miscellaneous Conditions”.
    • Clarified diabetes mellitus as type I in existing not covered policy statement.
    • Added a not covered policy statement for stem-cell transplantation for diabetes mellitus type 2.
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective August 15, 2016:
Abatacept (Orencia®) - (6112) Modified
  • Important changes in coverage:
    • Added statement that receipt of sampled product does not satisfy criteria requirements.
    • Added criteria that combination of Orencia with other biologic therapy will not be covered.
    • Added option of not a candidate for prior therapies (in addition to failure or inadequate response, contraindication per FDA label, or documented intolerance).
    • Modified criteria for intravenous Orencia for:
      • Rheumatoid arthritis to not a candidate for or unable to administer the subcutaneous formulation.
      • Polyarticular juvenile idiopathic arthritis to not a candidate for or unable to administer the preferred anti-tumor necrosis factor agent.
Brand Name Drugs 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:
    • Added Jentadueto® XR to DPP4 inhibitors and combinations.
    • Removed Betaseron®.
Brand Name Drugs 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:
    • Added Jentadueto XR to DPP4 inhibitors and combinations.
    • Removed Betaseron.
Multiple Sclerosis Therapy - (1402) Modified
  • Important changes in coverage:
    • For Employer Group Plans: Aubagio, Betaseron, Extavia, Gilenya, and Plegridy added as preferred brands; therefore, criteria were modified to remove preferred product requirements.
    • For Individual and Family Plans: No change to formulary status of products or criteria.
    • Modified criteria wording for Lemtrada® from failure to inadequate response to align with FDA indication language.
Pegfilgrastim (Neulasta®) - (1320) Modified
  • Important changes in coverage:
    • Added coverage for FDA approved indication:
      • Hematopoietic subsyndrome of acute radiation syndrome.
    • Added coverage for off-label indication:
      • Supportive care post-autologous hematopoietic cell transplant.
Quantity Limitations – (1201) Modified
  • Important changes in coverage:
    • Added Emend® suspension.
Rituximab (Rituxan®) for Non-Oncology Indications - (5108) Modified
  • Important changes in coverage:
    • Added coverage for pediatric nephrotic syndrome.
    • Removed Castleman’s disease and post-transplant lymphoproliferative disorder:
Ruxolitinib (Jakafi®) - (1211) Modified
  • Important changes in coverage:
    • Removed criteria requiring presence of splenomegaly.
    • Added a limited initial authorization of six months:
      • Reauthorization criteria require clinical improvement in symptoms.
Step Therapy – (1109) Modified
  • Important changes in coverage:
    • Added Jentadueto XR to the B-Step or Emerging Step Therapy program.
    • Added Fenortho to Global Step Therapy, NSAIDS, step 3.
Step Therapy Individual and Family Plans – (1603) Modified
  • Important changes in coverage:
    • Added Jentadueto XR to Step 2 of DPP4 inhibitors.
Tofacitinib (Xeljanz®) - (1410) Modified
  • Important changes in coverage:
    • Added new formulation, Xeljanz XR.
    • Added statement that receipt of sampled product does not satisfy criteria requirements.
    • Added definition of adult.
    • Added criteria that combination of Xeljanz/Xeljanz XR with other biologic therapy will not be covered.
    • Added option of not a candidate for prior therapies (in addition to failure or inadequate response, contraindication per FDA label, or documented intolerance).
Ustekinumab (Stelara®) - (1017) Modified
  • Important changes in coverage:
    • Added statement that receipt of sampled product does not satisfy criteria requirements.
    • Added criteria that combination of Stelara with other biologic therapy will not be covered.
    • Added option of not a candidate for prior therapies (in addition to failure or inadequate response, contraindication per FDA label, or documented intolerance).
    • Removed Crohn’s disease from list of experimental, investigational, or unproven (EIU) uses.
      • This remains an uncovered indication; however, data has been submitted to the FDA for review of this potential new indication.
Policies Status Details
Administrative Policies
No updates for August 2016.
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*
Precertification List Modified
  • Important changes effective August 26, 2016. Added the following to precert:
    • CPT codes 32195, 32196, 32197, 43210, 47143, 47144, 47145, 48550, 48551, and 48552.
    • HCPCS codes H0031, H0032, H2012, H2019, J2724, S3840, S3841, S3865, and S3866.
    • Removed many codes descoped from eviCore MSK program.
Policies Status Details
Reimbursement Policies*
R24 Omnibus Reimbursement Policy Modified
  • Important changes:
    • Added notification for documentation requirement beginning October 16, 2016, for cervical vertebral corpectomy when billed with cervical fusion.
      • Documentation must show at least 50 percent of vertebral body was removed.
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
Code Edit Guidelines and Code Edit Bulletin Modified
  • On August 13, 2016, ClaimsXten will be updated to third Quarter Knowledge Base content and NCCI Version 22.2 fior all medical and behavioral claims.
Code Edit Bulletin Modified
  • On August 13, 2016, to better align with CMS:
    • Cigna is implementing a Medically Unlikely Edit (MUE) through ClaimsXten for CPT codes 97001 through 97004, 97012 through 97024, and 97028.
    • These codes have a frequency limit of one unit per CMS guidelines.
Policies Status Details
Policies with a Reduction in Coverage**
** The following policy updates, effective August 26, 2016, will result in a reduction of coverage.
Balloon Sinus Ostial Dilation for Chronic Sinusitis - (0480) Modified
  • We will implement a new precertification requirement and medical coverage policy for balloon sinuplasty, effective August 26, 2016. This new policy outlines the medical necessity criteria that must be met for coverage of balloon sinuplasty to dilate one or more sinuses during a nasal endoscopy. Precertification will be required for balloon sinuplasty for Current Procedural Terminology (CPT®) codes 31295, 31296, and 31297.

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.