Policy Updates August 2018

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
There were no policy updates for August 2018 that resulted in a reduction in coverage.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective August 15, 2018:
Laser Interstitial Thermal Therapy - (0528) New
  • Advance notification originally provided on May 15, 2018, policy effective August 15, 2018:
    • Addresses laser interstitial thermal therapy (LITT), including magnetic resonance-guided laser interstitial thermal therapy (MRgLITT).
    • Added new not covered policy statement.
    • CPT codes already on precert:
      • 19499, 27599, 32999, 55899 and 64999
Surgical Treatments for Lymphedema and Lipedema – (0531) New
  • Addresses experimental, investigational or unproven (EIU) surgical treatments.
    • Codes require medical necessity review (MNR)/precertification.
Atherosclerotic Cardiovascular Disease Risk Assessment: Emerging Laboratory Evaluations - (0137) Modified
  • Important change in coverage criteria:
    • Added “GlycA (glycosylated acute phase proteins)” to existing EIU policy statement.

Bone Mineral Density Measurement - (0300)

Modified
  • Advance notification of important changes in coverage criteria, effective November 15, 2018:
    • Added new EIU policy statement for CPT code 0508T (pulse-echo ultrasound bone density measurement, tibia).
      • Code on precert as of July 1, 2018.
      • Code coming off precert on October 1, 2018.
        • Will be always EIU batch edit starting November 15, 2018.
Corneal Remodeling - (0141) Modified
  • Important change in coverage criteria:
    • Added new policy statement for coverage of corneal collagen crosslinking.
Prophylactic Mastectomy - (0029) Modified
  • Important change in coverage criteria:
    • Updated medical necessity criteria for individuals with a personal history of cancer.
Reduction Mammoplasty - (0152) Modified
  • Important change in coverage criteria:
    • Updated medical necessity criteria for macromastia.
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Unless otherwise noted, the following medical coverage policies were modified effective August 15, 2018:
Electric Stimulation for Pain, Swelling and Function in a Clinic Setting - (CPG 0272) New
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Unless otherwise noted, the following medical coverage policies were modified effective August 15, 2018:
Shoulder Surgery - Open and Arthroscopic Procedures – (CMM 315) Modified
  • Advance notification of important changes in coverage criteria of Comprehensive Musculoskeletal Management Shoulder Surgery - Open and Arthroscopic Procedures – (CMM 315) effective November 15, 2018.
    • Updated “Definition” and “General Guideline” sections with background information.
    • Added a new criterion for six months of function limiting pain and added clarification to medical necessity criteria for “Diagnostic Arthroscopy”.
    • Added new separate subsection and medical necessity criteria for loose body/foreign body removal.
    • Added a separate subsection and additional criteria for synovectomy and debridement.
    • Added clarification to remaining subsections.
    • Added new NMN statements for each section.
    • Removed references to “Manipulation Under Anesthesia (MUA) for Adhesive Capsulitis.”
High-Tech Radiology (HTR or imaging) Guidelines Modified
  • Advance notification of important changes in coverage criteria of cobranded high-tech radiology (HTR or imaging) Guidelines effective November 15, 2018.
    • Abdomen (Adult and Pediatric)
    • Breast (Adult only)
    • Chest (Adult and Pediatric)
    • Head (Adult and Pediatric)
    • Musculoskeletal (Adult and Pediatric)
    • Neck (Adult and Pediatric)
    • Pelvis (Adult and Pediatric)
    • Peripheral Vascular Disease (PVD) (Adult and Pediatric)
    • Peripheral Nerve Disease (PND) (Adult and Pediatric)
    • Spine (Adult and Pediatric)
Policies Status Details
Administrative Policies
  • No updates for August 2018.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective August 15, 2018:
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulators - (1207) Modified
  • Important changes in coverage criteria:
    • Added Symdeko to formulary as a non-preferred brand with prior authorization and quantity limit.
    • Revised title from ‘Ivacaftor, Lumacaftor/Ivacaftor’.
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 generic Uceris®: tablet criteria.
      • Modified Brand Uceris tablet criteria to include generic and reduce other corticosteroid requirements from five to one.
Hydroxyprogesterone caproate injection - (1108) Modified
  • Important changes in coverage criteria:
    • Detailed uses that are EIU.
      • No change to coverage criteria.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Added Braftovi and Mektovi® to pharmacy benefit table.
Palivizumab - (5012) Modified
  • Important changes in coverage criteria:
    • Expanded list of uses considered not medically necessary (NMN).
    • Modified list of uses considered EIU.
Quantity Limitations - (1201) Modified
Rituximab for Non-Oncology Indications - (5108) Modified
  • Important changes in coverage criteria:
    • Updated criteria to specify coverage for pemphigus vulgaris and other refractory autoimmune blistering diseases.
    • Added coverage for thrombotic thrombocytopenic purpura.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • One policy updated for August 2018.
Policies Status Details
Precertification Policies*
  • No updates for August 2018.
Policies Status Details
Reimbursement Policies*
  • No updates for August 2018.
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
  • No updates for August 2018.

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.