Policy Updates August 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective August 15, 2017:
Transthoracic Echocardiography in Children – (0523) New
  • Advance notification provided on May 15, 2017 for policy effective August 19, 2017:
    • Supports initial outpatient nonstress transthoracic echocardiography (TTE) in individuals age 17 years or younger.
    • Addresses outpatient hospitals off-campus (Place of Service [POS] 19), outpatient hospitals on-campus (POS 22), and provider’s office (POS 11).
    • Does not address serial or subsequent TTE.
    • Does not address stress TTE.
Atherosclerotic Cardiovascular Disease Risk Assessment: Emerging Laboratory Evaluations – (0137) Modified
  • Important changes in coverage criteria:
    • Added numerous tests to existing experimental, investigational or unproven (EIU) policy statement.
Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis – (0514) Modified
  • Important change in coverage criteria:
    • Updated criteria in existing coverage policy statement for genetic testing for spinal muscular atrophy.
Reduction Mammoplasty – (0152) Modified
  • Important change in coverage criteria:
    • Added a not medically necessary policy statement.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy (drugs & biologics) coverage policies were modified effective August 15, 2017:
Antiemetic Therapy – (1705) New
  • Supports medical precertification of Sustol (granisetron extended release for subcutaneous injection):
Controlled Substance Analgesic and Narcotic Antagonist Quantity Limitations - (1706) Modified
  • Important changes in coverage criteria:
    • Added Arymo ER and Morphabond ER to the Long Acting Opioids section, Morphine Sulfate subsection.
      • Both products moved from 180 day hold.
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:
    • Removed criteria for alogliptin, alogliptin/metformin, and alogliptin/pioglitazone.
      • Updated criteria for Nesina, Kazano, Tradjenta®, and Jentadueto/Jentadueto XR to include generic alogliptin or alogliptin/metformin.
    • Updated criteria for Oseni to mirror approach taken with other combinations and to require generic.
    • Added criteria for AirDuo and added generic fluticasone/salmeterol as an alternative for AirDuo and Dulera.
    • Removed levorphanol criteria with redirect to Opioid Therapy - (1704).
    • Added criteria for Auvi-Q and Trulance.
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:
    • Removed criteria for alogliptin, alogliptin/metformin, and alogliptin/pioglitazone.
      • Updated criteria for Nesina, Kazano, Tradjenta, and Jentadueto/Jentadueto XR to include generic alogliptin or alogliptin/metformin.
    • Updated criteria for Oseni to mirror approach taken with other combinations and to require generic.
    • Removed criteria for Symbicort®, added criteria for AirDuo, and added generic fluticasone/salmeterol and Symbicort as alternatives for AirDuo and Dulera.
    • Removed levorphanol criteria with redirect to Opioid Therapy - (1704).
    • Added criteria for Auvi-Q and Trulance.
    • Added criteria for Novolin insulins and Novolog combination product.
    • Added “not a candidate” language to the criteria for Tresiba and Levemir.
    • Removed criteria for Byetta/Bydureon as preferred brand.
      • Updated criteria for Adlyxin, Tanzeum, and Victoza to include Byetta/Bydureon as covered alternatives.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Added new drugs:
      • Nerlynx and Xermelo (pharmacy benefit)
      • Rituxan Hycela (medical benefit)
Opioid Therapy - (1704) Modified
  • Important changes in coverage criteria:
    • Added Arymo ER and Morphabond ER as nonpreferred brands.
    • Added levorphanol medical necessity criteria.
Oxazolidinone Antibiotics - (1123) Modified
  • Important change in coverage criteria:
    • Added previously approved interim criteria for Individual and Family Plans requiring use of generic Zyvox tablets or suspension.
Pharmacy Prior Authorization - (1407) Modified
  • Important changes in coverage criteria:
    • Added previously approved interim criteria for:
      • Austedo (deutetrabenazine)
      • Ingrezza (valbenazine)
    • Added crtieria for:
      • Basaglar (insulin glargine)
      • Lupaneta Pack (leuprolide acetate for depot suspension and norethindrone acetate)
      • Ravicti (glycerol phenylbutyrate)
Ruxolitinib - (1211) Modified
  • Important changes in coverage criteria:
    • Added International Prognostic Scoring System (IPSS) to myelofibrosis criteria to document for diagnosis.
    • Added coverage of symptomatic low-risk myelofibrosis.
      • Both changes above are in alignment with NCCN myelofibrosis guidelines.
    • Added graft versus host disease, leukemia, pancreatic cancer to EIU section.
    • Removed trade name from title.
Step Therapy – (1109) Modified
  • Important changes in coverage criteria:
    • Added two long-acting opioids to step 3:
      • Arymo ER
      • Morphabond ER
    • Added respiratory (inhaled corticosteroids/long-acting beta-agonists):
      • AirDuo Respiclick to step 3
      • fluticasone/salmeterol to step 2
    • Removed Glyxambi and Oleptro as target drugs from emerging step therapy.
    • Added Trulance with prerequisites of Amitiza or Linzess.
Unassigned Drug or Biologic Code Medical Precertification - (1701) Modified
  • Important changes in coverage criteria:
    • Removed Sustol (granisetron extended-release for subcutaneous injection) criteria:
    • Added criteria for Defitelio (defibrotide) consistent with interim approach.
Policies Status Details
Administrative Policies
No updates for August 2017.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Fifteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
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Policies Status Details
Precertification Policies*
Updates have been made to the following:
Master Outpatient Precertification List Modified
Policies Status Details
Reimbursement Policies*
Updates have been made to the following:
R24 Omnibus Reimbursement Policy Modified
R14 Pharmacy and Infusion Services Modified
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
Updates have been made to the following:
Code Edit and Policy Guidelines Modified
Policies Status Details
Policies with a Reduction in Coverage
We are changing how we reimburse providers as follows:
Implantable Hormone Pellets (1504)

Currently, claims for Testopel® may be reviewed for medical necessity if the requested amount exceeds a certain threshold. We will require prior authorization for coverage of all Testopel requests. The update is effective for claims billed with HCPCS code S0189 and CPT® code 11980.

The update is effective for UB and HCFA claims with dates of service on or after August 25, 2017.

The effective date for Individual & Family Plans is January 1, 2018.

Transthoracic Echocardiography in Adults (0510)

Transthoracic Echocardiography in Children (0523)

The Transthoracic Echocardiography in Adults policy applies only to those age 18 or older. Claims are currently reviewed only for adults, and only when the provider’s office is the place of Service (POS11).

We created a new policy, Transthoracic Echocardiography in Children. We will begin to review claims for adults and children for TTEs performed in outpatient hospitals off-campus (POS 19), outpatient hospitals on-campus (POS 22), and in a provider’s office (POS 11).

This update is effective for UB and HCFA claims with dates of service on or after August 21, 2017.


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.