Policy Updates August 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 policies:
Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery (0481)

  • We will deny claims for drug-eluting stents following sinus surgery as being experimental, investigational, and unproven (EIU). This update aligns with our current medical coverage policy, Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery (0481).
  • The affected Healthcare Common Procedure Coding System (HCPCS) codes are C1874, C1875, C1876, C1877, C2617, and C2625.
  • This update is effective for dates of service beginning August 19, 2019.
Orthotic Devices and Shoes (0543)
  • We will implement a new medical coverage policy, Orthotic Devices and Shoes (0543), and deny claims billed for orthotic prescriptions costing $250 or greater as not medically necessary if the referring provider did not conduct an in-person evaluation of the patient within six months before the date of service.
  • Additionally, claims that do not include a referring provider will be pended for additional information. This update applies to spine, knee, and lower and upper limb orthotic devices.
  • Note: The new policy will replace the following existing policies:
    • Cranial Orthotic Devices for Deformational and Positional Plagiocephaly (0056)
    • Lower Limb Orthoses and Shoes (0150)
    • Myoelectric Devices: Upper Limb (0233)
    • Knee Braces (0362)
    • Spinal Orthoses (0394)
  • This policy is effective for dates of service beginning August 19, 2019.
Vitamin D Testing (0526)
  • We will update our current medical coverage policy, Vitamin D Testing (0526), to add a frequency limit of two lab tests in a 365-day rolling period for claims billed with CPT 82306 (Vitamin D; 25 Hydroxy). This frequency limit does not apply to vitamin D testing for chronic kidney disease and malabsorption syndromes.
  • Additionally, please note that this does not affect other terms of our policy regarding vitamin D testing, including coverage for routine vitamin D screening.
  • We also will limit testing per date of service to one code. As such, we will deny claims billed with CPT code 82652 (Vitamin D; 1, 25 Dihydroxy) in combination with CPT code 82306 as being duplicative.
  • This update is effective for dates of service beginning August 19, 2019.

Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, Including Sacroiliac Fusion (0303)

Cervical Fusion (0527)

Bone, Cartilage and Ligament Graft Substitutes (0118)

  • We will update three coverage policies to require precertification for spinal fusion-related codes. We will review these codes under the precertification requirements for the primary procedure.
  • The affected medical coverage policies are Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, Including Sacroiliac Fusion (0303); Cervical Fusion (0527); and Bone, Cartilage and Ligament Graft Substitutes (0118).
  • These updates are effective for dates of service beginning August 23, 2019.
Venous Angioplasty With or Without Stent Placement for Adults (0541)
  • We will update our current medical coverage policy, Venous Angioplasty With or Without Stent Placement for Adults (0541), to require precertification. This policy affects adults age 18 and older.
  • The affected CPT codes are 37238, 37239, 37248, and 37249.
  • This update is effective for dates of service beginning August 23, 2019.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective August 15, 2019:
Implantable Electrocardiographic Event Monitors – (0547) New
  • Advance notification posted July 18, 2019, effective October 23, 2019:
    • Precertification will be required.
Orthotic Devices and Shoes – (0543) New
  • Originally provided advance notification on May 15, 2019:
    • Combines information from the following policies being retired:
      • Cranial Orthotic Devices for Positional or Deformational Plagiocephaly – (0056)
      • Knee Braces – (0362)
      • Lower Limb Orthoses and Shoes – (0150)
      • Myoelectric Devices: Upper Limb – (0233)
      • Spinal Orthosis – (0394)
    • New policy statement with medical necessity criteria for upper limb orthotic devices.
    • New edit will deny upper limb, lower limb, knee braces and spinal orthosis when there is no physical exam
    • Added AposTherapy® biomechanical device to experimental, investigational, or unproven (EIU) policy statement.
Venous Angioplasty With or Without Stent Placement for Adults – (0541) New
  • Originally provided advance notification on May 15, 2019, effective August 23, 2019:
    • Precertification will be required
    • Not previously managed.

Cervical Fusion – (0527)

Modified
  • Originally provided advance notification of important changes in coverage criteria on May 15, 2019:
    • Codes now require precertification.
    • Will be denied when primary fusion procedure is denied.
  • Additional important changes in coverage criteria:
    • Added clarification requiring physical exam findings consistent with imaging for revision fusion.
    • Added new not covered policy statement for isolated facet joint fusion.
Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery – (0481) Modified
  • Originally provided advance notification of important changes in coverage criteria on May 15, 2019:
    • Implementing existing EIU policy statement.
Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, Including Sacroiliac Fusion - (0303) Modified
  • Originally provided advance notification of important changes in coverage criteria on May 15, 2019:
    • Codes now require precertification.
    • Will be denied when primary fusion procedure is denied.
Male Sexual Dysfunction Treatment: Non-pharmacologic - (0403) Modified
  • Important changes in coverage criteria, effective August 1, 2019:
    • Removed requirement that erectile dysfunction must be caused by an organic etiology.
    • Added requirement that erectile dysfunction must persist for six months before surgical implantation of penile prosthesis.
    • Added requirement that a comprehensive history and physical exam, including appropriate laboratory testing, has been completed.
Nucleic Acid Pathogen Testing – (0530) Modified
  • Advance notification of important changes in coverage criteria, posted August 1, 2019, effective November 1, 2019:
    • Removed coverage for several symptom-related diagnosis codes related to Gardnerella.
      • Will continue to cover for high-risk behaviors.
    • Added clarification to the asymptomatic bullet of the first policy statement.
Prosthetic Devices – (0536) Modified
  • Important changes in coverage criteria:
    • Added policy statements for codes that require only a specific functional level for medical necessity.
Reduction Mammoplasty - (0152) Modified
  • Minor changes in coverage/policy:
    • Added clarifying language to existing policy statement.
Transthoracic Echocardiography in Adults – (0510) Modified
  • Advance notification of minor changes in coverage criteria/policy with associated edits effective October 19, 2019:
    • Revised policy statement wording about therapy for malignancy.
    • Added policy statement language to be more explicit about echo being indicated for mediastinal masses or concern for any impingement of structure on the heart.
Transthoracic Echocardiography in Children – (0523) Modified
  • Minor changes in coverage criteria/policy::
    • Revised policy statement wording about chemotherapy.
    • Added policy statement language to be more explicit about echo being indicated for mediastinal masses or concern for any impingement of structure on the heart.
    • No edit changes needed.
Vision Therapy/Orthoptics – (0221) Modified
  • Important change in coverage criteria:
    • Added coverage for vision therapy/orthoptics for convergence insufficiency.
Vitamin D Testing - (0526) Modified
  • Originally provided advance notification on May 15, 2019 of important changes in coverage criteria, effective August 19, 2019:
    • Added new frequency not medically necessary (NMN) edit:
      • Deny 82306 if three or more tests in 12 rolling months for the same member.
      • Exceptions include chronic kidney disease (CKD) or intestinal malabsorption.
    • Added new duplicate NMN edit:
      • Deny 82652 if billed with 82306 for the same member on the same date of service, regardless of provider.
    • New edits apply to all ages.
    • Existing edit applies to ages 18 – 64 years.
Prophylactic Mastectomy – (0029) Retired
  • No longer has business value; therefore, will no longer be maintained.

Cranial Orthotic Devices for Positional or Deformational Plagiocephaly – (0056)

Knee Braces – (0362)

Lower Limb Orthoses and Shoes – (0150)

Myoelectric Devices: Upper Limb – (0233)

Spinal Orthosis – (0394)

Retired
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Updated Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations – (CPG 111)
  • Not a standard policy; is a listing and description of evaluation and re-evaluation codes.
  • Re-arrangement of codes but no substantive changes.
Updated Electric Stimulation for Pain, Swelling and Function in a Clinic Setting – (CPG 272)
  • Added additional EIU policy statements.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Important changes to the following Cigna-eviCore Cobranded Comprehensive Musculoskeletal Management (CMM) guidelines:
  • Shoulder Surgery Arthroscopic and Open - (CMM 315)
    • Added superior capsular reconstruction and arthroscopic/open coracoplasty as EIU.
  • Spinal Cord Stimulator - (CMM 211)
    • Added clarification for low frequency and high frequency devices.
Originally provided advance notification on May 15, 2019 of updates to the following Cigna-eviCore Cobranded Comprehensive Musculoskeletal Management (CMM) guidelines:
  • Knee Surgery Arthroscopic and Open - (CMM 312)
    • Added new policy statement addressing hybrid autologous chondrocyte implantation.
Policies Status Details
Administrative Policies
Preventive Care Services – (A004) Modified
  • Important correction to Breast Feeding Equipment/Supplies:
    • Updated to note hospital grade breast pump, HCPCS code E0604, requires a prescription.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective August 1, 2019:
New
New
Complement Inhibitors – (1103) Modified
  • Important changes in coverage criteria:
    • Retitled from Eculizumab to Complement Inhibitors:
      • Policy now includes eculizumab and ravulizumab.
    • Added criterion requiring specialist consultation for all uses of complement inhibitors consistent with subject matter experts’ recommendations on eculizumab and ravulizumab.
    • Added criterion screening for meningococcal vaccination requirements consistent with product label.
    • Additional modifications without substantive impact to coverage criteria.
    • Updated eculizumab reauthorization criteria for paroxysmal nocturnal hemoglobinuria (PNH) and generalized myasthenia gravis (gMG) uses with examples of positive clinical response.
    • Updated ravulizumab reauthorization criteria for PNH use with examples of positive clinical response.
    • Added initial and reauthorization intervals:
      • No changes to current implementation.
Dupilumab - (1810) Modified
  • Important changes in coverage criteria:
    • Added new indication for Dupixent’s use as add-on maintenance therapy for the treatment of chronic rhinosinusitis with nasal polyposis.

Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List – (1601)

Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List – (1602)

Modified
  • Minor changes in coverage criteria/policy:
    • Added criterion for EryPed 400 suspension requiring intolerance to one generic formulation of the agent responsive to business decision.
    • Added criteria for generic doxycycline 80 mg tablets requiring covered alternatives first responsive to business decision.
    • Removed criteria for Trulance (plecanatide) responsive to a business decision:
      • Effective October 1, 2019.
    • Removed criteria for Uceris (budesonide 9 mg extended release tablets), budesonide 9 mg extended release tablets, and Uceris (budesonide 2 mg rectal foam) responsive to creation of Budesonide (Uceris®) – (P0084)
Human Papillomavirus Vaccine - (6018) Modified
  • Important changes in coverage criteria:
    • Added coverage for 9-valent human papillomavirus recombinant vaccine (Gardasil 9) ages 27 through 45 years based on shared clinical decision making responsive to Advisory Committee on Immunization Practices (ACIP) recommendation.
    • Added footnote below criteria statements to indicate age criteria apply to dates of service before February 16, 2019, responsive to a business decision.
Hydroxyprogesterone Caproate Injection - (1108) Modified
  • Important changes in coverage criteria:
    • Added step-through of generic Makena/Makena PF before brand Makena/Makena PF secondary to a business decision.
    • Updated background information: Professional Societies section and references.
Immunomodulators - (Individual and Family Plans) – (1903) Modified
  • Important changes in coverage criteria:
    • Removed non-radiographic axial spondyloarthritis as part of ankylosing criteria:
      • Added stand-alone criteria for diagnosis of non-radiographic axial spondyloarthritis, which includes demonstration of objective signs of inflammation.
Immunomodulators – Oral and Subcutaneous (Employer Group Benefit Plans) – (1805) Modified
  • Important changes in coverage criteria:
    • Added a triple step for diagnosis of plaque psoriasis (from two to three steps) for Taltz (ixekizumab).
    • Added a double step for diagnosis of Crohn’s Disease (from one to two steps) for Cimzia (certolizumab pegol).
      • Both changes made responsive to a business decision from PCC on June 20, 2019.
    • Removed non-radiographic axial spondyloarthritis as part of ankylosing criteria:
      • Added stand-alone criteria for diagnosis of non-radiographic axial spondyloarthritis, which includes demonstration of objective signs of inflammation.
Medication Administration Site of Care – (1605) Modified
  • Minor changes in coverage criteria/policy:
    • Added all of the following to the Enhanced Specialty Care Options program list in policy background supporting redirection of site of care:
      • Added Cutaquig® (Immune Globulin Subcutaneous [Human] – hipp) to the covered drugs table:
        • HCPCS codes C9399, J3490, J3590, 90284 can be used.
        • Codes already in policy.
      • Added Evenity (romosozumab-aqqg) to the covered drugs table:
        • HCPCS codes C9399, J3490, J3590 can be used.
        • Codes already in policy.
Ocriplasmin - (1310) Modified
  • Minor changes in coverage criteria/policy:
    • Moved the single-use criterion from the initial criteria statement to the EIU criteria statement.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Added embedded step therapy criterion for Infugem requiring one generic formulation of Gemzar responsive to business decision.
    • Added embedded step therapy criterion for Zytiga requiring use with the generic formulation (abiraterone) responsive to business decision:
      • Effective January 1, 2020.
    • Added non-oncological use criteria for bleomycin sulfate for treatment of recalcitrant verruca vulgaris responsive to criteria followed as per Medical Inquiry Database (MID).
    • Added non-oncological use criteria for Jakafi (ruxolitinib) for graft vs. host disease responsive to expanded FDA-approved uses from May 2019.
    • Reformatted criteria stem distinguishing agents with specific additional criteria to be satisfied from agents where coverage requires the use of a preferred product.
Oral Phosphodiesterase-5 (PDE5) Inhibitors - (7003) Modified
  • Minor change in coverage criteria/policy:
    • Removed erectile dysfunction of psychological origin from NMN list.
Pharmacy Prior Authorization – (1407) Modified
Pulmonary Hypertension (PH) - (6121) Modified
  • Important changes in coverage criteria:
    • Updated to conform to 2019 policy template:
      • Added initial and reauthorization duration of up to 12 months; standard reauthorization criteria statement.
    • Added another generic form of Adcirca, Alyq.
Step Therapy – (1109) Modified
  • Minor changes in coverage criteria:
    • Added doxycycline 80 mg tablets to Emerging Drug Therapy table responsive to business decision.
    • Added statement that step therapy for Trulance will no longer apply responsive to business decision:
      • Effective October 1, 2019.
Step Therapy – (1803) Modified
  • Minor changes in coverage criteria:
    • Added doxycycline 80 mg tablets to step of the tetracyclines, doxycycline class responsive to business decision.
    • Added statement that step therapy for Trulance will no longer apply responsive to business decision:
      • Effective October 1, 2019.
Teduglutide - (1318) Modified
  • Important change in coverage criteria:
    • Revised age to one year of age and older due to expanded FDA label.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for August 2019
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
  • No updates for August 2019.
Policies Status Details
ClaimsXten*
Code Edit and Policy Guidelines Modified
  • Important changes effective August 17, 2019:
    • ClaimsXten will be updated to Third Quarter Knowledge Base content and NCCI Version 25.2 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] July differ significantly from the standard benefit plans upon which these policies are based. For example, a customer's benefit plan document July 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 July be used to support medical necessity and other coverage determinations.