Policy Updates August 2020

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 Update to Coverage
We are changing how we reimburse for the following policies:
Facilities Reimbursement Policy (R09)
  • We will update the National Correct Coding Initiatives (NCCI) for Facilities Reimbursement Policy (R09) to add additional code pairs to the code pair list.
  • This update is effective for claims processed on or after August 16, 2020.
Intraoperative Monitoring (0509)
  • We will deny coverage for intraoperative monitoring (IOM) and the baseline electrodiagnostic procedures when performed during surgery at or below spinal level L1 as being not medically necessary.
  • This update is effective for dates of service beginning August 16, 2020.
Nucleic Acid Pathogen Panel (0530)
  • We will review tests for medical necessity in alignment with our Nucleic Acid Pathogen Panel (0530) medical coverage policy.
  • This update is effective for dates of service beginning August 16, 2020.
  • This policy update does not include testing for COVID-19.
Omnibus Reimbursement Policy (R24)
  • We will deny reimbursement for a prostate needle biopsy when billed with Current Procedural Terminology (CPT®) code 88305.
  • Claims may be resubmitted with the appropriate Healthcare Common Procedure Coding System (HCPCS) code G0416 with one unit.
  • This update is effective for claims processed on or after August 18, 2020.
Policies Status Details
Medical Coverage Policies
  • Unless otherwise noted, the following medical coverage policies were modified effective August 15, 2020:
  • Please note – Going forward, as medical coverage policies are created and/or updated, we will include expanded Medicare information in each policy. Users can link to the Medicare policy table from the table of contents contained in each coverage policy.
  • Category III Current Procedural Terminology (CPT®) codes – (0558) New
    • Advance notification of new policy effective November 15, 2020:
      • Addresses Category III codes, or T codes:
        • Codes are a set of temporary (T) codes assigned to emerging technologies, services, and procedures.
        • The use of Category III codes allow doctors and other qualified health care professionals to identify emerging technology, services, and procedures for clinical efficacy, utilization, and outcomes.
        • Because of the specific purpose the CPT Category III codes serve, the service or procedure represented by these codes are considered experimental, investigational, or unproven (EIU) unless there is a Cigna Coverage Policy that specifically extends coverage to a particular Category III code.
        • Coverage policies containing T codes considered medically necessary are listed in the policy and include hyperlinks.
    Diabetes Equipment and Self-Management - (0106) Modified
    • Important change in coverage criteria, effective August 1, 2020:
      • Added coverage for the Freestyle Libre 2 implantable continuous glucose monitoring system.
    Duplex Scan to Evaluate for Carotid Artery Stenosis - (0542) Modified
    • Advanced notification for important changes in coverage criteria, effective November 16, 2020:
      • Added code to coding section to expand edit to include unilateral study.
        • CPT code 93882 - Duplex scan of extracranial arteries; unilateral or limited study.
        • Edit expansion will begin denying some unilateral duplex studies per existing policy statement.
        • No change to coverage policy statement.
    Liver Transplantation - (0355) Modified
    • Important changes in coverage criteria originally posted May 15, 2020, changes effective August 15, 2020:
      • Added criterion for hepatocellular carcinoma requiring alpha-fetoprotein (AFP) level less than or equal to 1000 nanograms per milliliter (ng/mL).
      • Clarified language about unresectable cholangiocarcinoma and hepatoblastoma.
    Male Sexual Dysfunction Treatment: Non-pharmacologic - (0403) Modified
    • Important changes in coverage criteria:
      • Numerous updates to support requiring individual to fail medical management before proceeding to surgical treatment of erectile dysfunction (ED).
      • Vacuum devices are considered medical management and pharmacological treatment is not required to be eligible for a vacuum erection device.
        • Removed statement “failure, contraindication or intolerance to FDA approved pharmacological therapy (e.g., oral PDE5 inhibitors, intracavernosal injection, intraurethral medication)”.
        • Removed statement that vacuum constriction device is not medically necessary for any other indication.
        • Changed the term vacuum constriction device to vacuum erection device.
        • Clarified medical necessity language for penile prosthesis to include failure, contraindication or intolerance to medical management of pharmacological therapy and/or vacuum erection device.
    Minimally Invasive Anti-Reflux Procedures and Peroral Endoscopic Myotomy (POEM) Procedures – (0019) Modified
    • Important changes in coverage criteria:
      • Updated title:
        • Added “procedures” to end of current title.
      • Added and updated policy statements on POEM to cover when certain criteria are met.
      • Expanded scope to include additional POEM procedures:
        • Gastric, Diverticular and Zenker.
      • Added new endoscopic technique, resection and plication (RAP).
    Minimally Invasive Spine Surgery Procedures and Trigger Point Injections - (0139) Modified
    • Minor changes in coverage criteria/policy:
      • Clarified policy statement.
    Neuropsychological Testing - (0258) Modified
    • Minor changes in coverage criteria/policy:
      • Clarified policy statement.
    Nucleic Acid Pathogen Testing - (0530) Modified
    • Originally provided advance notification of important changes in coverage criteria on May 15, 2020, changes effective August 15, 2020:
      • Added new not medically necessary (NMN) claims edit to support policy statement on infectious pathogen detection by nucleic acid panel.
        • CPT codes not covered: respiratory (87632, 87633); gastrointestinal (87506, 87507).
    Omnibus Codes - (0504) Modified
    • Important changes in coverage criteria:
      • Added new CPT codes considered experimental, investigational or unproven (EIU).
    Reduction Mammoplasty - (0152) Modified
    Sleep Apnea Treatment Services – (0158) Modified
    • Important changes in coverage criteria:
      • Updated title: removed the word “Obstructive” from previous title “Obstructive Sleep Apnea Treatment Services”
    Tissue-Engineered Skin Substitutes - (0068) Modified
    • Important changes in coverage criteria:
      • Added 22 new HCPCS codes for new or existing products considered EIU.
    Transthoracic Echocardiography in Adults - (0510) Modified
    • Originally provided advance notification of important changes in coverage criteria on June 15, 2020, for changes effective August 15, 2020:
      • Added policy statement addressing pre-operative transthoracic echocardiography (TTE) before noncardiac solid organ transplantation.
      • Updated transplant-related ICD10 coding.
    Transthoracic Echocardiography in Children – (0523) Modified
    • Originally provided advance notification of important changes in coverage criteria on June 15, 2020, for changes effective August 15, 2020:
      • Added policy statement addressing transplantation-related TTE.
      • Updated transplant-related ICD10 coding.
    Policies Status Details
    American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
    Electric Stimulation for Pain, Swelling and Function in a Clinic Setting - (CPG 272): Modified
    • Updated with no change in coverage.
    Policies Status Details
    Cigna-eviCore Cobranded Guidelines
    Comprehensive Musculoskeletal Management (CMM) guidelines Modified
    • Annual review with no change in coverage criteria:
      • Epidural Adhesiolysis (CMM-207)
      • Facet Joint Injections (CMM-201)
      • Implantable Drug Delivery Systems (CMM-210)
      • Prolotherapy (CMM-204)
      • Radiofrequency Joint Ablation/Denervation (CMM-208)
      • Spinal Cord Stimulators (CMM-211)
    Comprehensive Musculoskeletal Management (CMM) guidelines Modified
    • Annual review with important changes in coverage criteria:
      • Knee Surgery Arthroscopic and Open (CMM-312):
        • Reduced physical therapy (PT) requirement for lysis of adhesions to a trial of PT versus the previous two month requirement.
      • Sacroiliac Joint Injections (CMM-203)
        • Advance notification of changes effective November 15, 2020:
        • Changed pain reduction percent requirement from >50% to >75%.
      • Shoulder Surgery Arthroscopic and Open (CMM-315)
        • Updated PT requirement for lysis of adhesions to a trial of PT.
    High-Tech Radiology (HTR or Imaging) guidelines Modified
    • Originally provided advance notification that the following guidelines were revised May 22, 2020, effective August 21, 2020:
      • Oncology Adult
      • Oncology Pediatric
    Radiation Oncology guidelines Modified
    • Important changes effective August 4, 2020:
      • Added one new guideline for vulvar cancer.
      • Removed Xofigo from bone metastases guideline to be a standalone guideline.
        • No change in coverage for either policy.
      • Updated three guidelines with changes in coverage:
        • Image-guided radiation therapy (IGRT):
          • Use of IGRT is based on medical necessity for specific diagnoses.
          • A requirement from the vendor does not support medical necessity of IGRT.
        • Pancreatic neoadjuvant radiation therapy:
          • No longer medically necessary for patients with disease that is fully resectable.
        • Small cell lung cancer:
          • Decreased fractions allowed for palliation from 15 to 10.
    Policies Status Details
    Administrative Policies
    Preventive Care Services - (A004) Modified
    • Important changes:
      • Added CPT codes 90619 and 90694 to routine immunizations section.
    Policies Status Details
    Pharmacy (Drugs & Biologics) Policies
    Unless otherwise noted, the following pharmacy coverage policies were modified effective August 1, 2020:
    Supports pharmacy prior authorization requirements. New
    Supports medical precertification requirements. New
    Carglumic acid – (P0112) New
    • Criteria pulled from Pharmacy Prior Authorization – (1407) to create this new policy.
      • Added documentation of diagnosis by genetic testing or hyperammonemia (lab value).
      • Added specialists requirement:
        • Specialist includes metabolic specialist or one who specializes in metabolic diseases.
      • Added requirement of protein-restricted diet to align with FDA labeling.
      • Added authorization and reauthorization limits of 12 months (if confirmed through genetic testing) or 3 months (if lab reporting hyperammonemia).
      • Added continued use criteria that initial criteria are met and that treatment has resulted in a decrease in plasma ammonia levels from baseline.
    Cysteamine bitartrate delayed-release – (P0116) New
    • Criteria pulled from Pharmacy Prior Authorization – (1407) to create this new policy.
      • Updated criteria regarding diagnostic confirmation.
      • Added specialist requirement:
        • Nephrologist or metabolic specialist/or a specialist who focuses on metabolic diseases.
      • Added that individual will not be on both Cystagon (cysteamine bitartrate capsules) and Procysbi concurrently.
    Glycerol phenylbutyrate – (P0113) New
    • Criteria pulled from Pharmacy Prior Authorization – (1407) to create this new policy.
      • Added:
        • Examples of urea cycle disorders.
        • Confirmation of diagnosis by genetic testing or hyperammonemia (lab value).
        • Requirement of a protein-restricted diet.
        • Individual is not taking Buphenyl and Ravicti concurrently.
        • Specialists requirement:
          • Specialist includes metabolic disease specialist or specialists who focuses on metabolic diseases.
    Uridine triacetate – (P0115) New
    • Criteria pulled from Pharmacy Prior Authorization – (1407) to create this new policy.
      • Added documentation by genetic testing or by having first-degree relative with hereditary orotic aciduria or elevated urinary orotic acid level (lab value).
      • Added specialist requirement:
        • Specialist includes metabolic specialist or doctor who specializes in hereditary orotic aciduria.
    Budesonide (Uceris) – (P0084) Modified
    • Important changes in coverage criteria:
      • Removed requirement of steroid for oral Uceris and budesonide extended-release tablets (9 milligram tablets).
      • Removed requirement of hydrocortisone rectal suppository or mesalamine products (rectal enema or suppository) for Uceris foam.
    Carbidopa and levodopa enteral suspension - (1606) Modified
    • Important changes in coverage criteria:
      • Added expanded "not a candidate" to prerequisite steps, to insure requirements are only applied to new starts.
      • Increased number of required prerequisite steps from two to three.
      • Added specialist prescribing requirement.
    Chimeric Antigen Receptor T-Cell (CAR-T) and Advanced Cellular/Immune Effector Cell Therapy - (1808) Modified
    • Important changes in coverage criteria:
      • Yescarta:
        • Added criteria to expand coverage approval for diffuse large B-cell lymphoma arising from nodal marginal zone lymphoma.
      • Kymriah: Acute lymphoblastic leukemia (ALL):
        • Added criteria to expand coverage for minimal residual disease positive after consolidation therapy.
        • Added criteria to expand coverage for Philadelphia chromosome-positive disease with less than complete response, high-risk genetics, tyrosine kinase inhibitor intolerant or refractory disease, and relapse post-hematopoietic stem cell transplant.
      • B-Cell Lymphoma:
        • Added criteria to expand coverage approval for diffuse large B-cell lymphoma arising from nodal marginal zone lymphoma.
    COVID-19 Drug/Biologic Therapeutics – (2016) Modified
    • Minor changes in coverage criteria/policy:
      • Updated effective and next review dates.
      • Updated general background content.
    Dupilumab – (1810) Modified
    • Minor changes in coverage criteria/policy:
      • Modified criteria for atopic dermatitis for age down to six years of age.
    Immunomodulators – Oral and Subcutaneous (Employer Group Benefit Plans) – (1805) Modified
    • Important changes in coverage criteria:
      • Modified criteria to remove step therapy for Otezla and add as alternative for nonpreferred products for psoriatic arthritis.
      • Modified criteria to move Simponi from nonpreferred brand column to preferred brand with step therapy required for ulcerative colitis.
    Isavuconazonium – (P0011) Modified
    • Important changes in coverage criteria:
      • Added criterion expanding coverage for continuation therapy of documented Cresemba initiated by intravenous infusion.
    Mecasermin – (6107) Modified
    • Important changes in coverage criteria:
      • Added initial criteria bullet point for “Bony epiphyses are open” for both indications.
      • Removed auxologic and diagnostic evaluation criteria, evidence of GH1 gene mutation, and presence of growth hormone (GH) neutralizing antibodies from indication for GH gene deletion with development of neutralizing antibodies to GH.
    Opioid Therapy - (1704) Modified
    • Important changes in coverage criteria:
      • Removed Arymo ER, Exalgo and Opana ER from extended-release opioid analgesic products table.
      • Incorporated tramadol 100 mg tablet criteria.
      • Updated opioid therapy management agreement statement to only require signature of individual being treated.
    Pharmacy Prior Authorization – (1407) Modified
    Rilonacept – (P0007) Modified
    • Minor changes in coverage criteria/policy:
      • Added COVID-19 (Coronavirus Disease 2019), which includes cytokine release syndrome associated with COVID-19 to EIU section.
    Routine Immunizations - (9001) Modified
    • Minor changes in coverage criteria/policy:
      • Moved CPT code 90619 to covered section of coding table.
    Sodium Oxybate - (P0075) Modified
    • Important changes in coverage criteria:
      • Added statement excluding use with other sedative hypnotic agents or alcohol.
      • Removed concurrent use with other sedative hypnotic drugs from EIU statement.
      • Added statement excluding use in individuals diagnosed with succinic semialdehyde dehydrogenase deficiency to EIU statement.
    Teduglutide – (1318) Modified
    • Minor changes in coverage criteria/policy:
      • Added specialist requirement.
    Topical Acne – (P0049) Modified
    • Important changes in coverage criteria:
      • Removed 0.3% strength specification from Differin gel formulation criteria.
      • Added Zilxi 1.5% topical foam.
    Viscosupplementation for Osteoarthritis - (1405) Modified
    • Minor changes in coverage criteria/policy:
      • Added Triluron as nonpreferred brand.
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    • No updates for August 2020
    Policies Status Details
    Precertification Policies*
    Policies Status Details
    Reimbursement Policies*
    Policies Status Details
    ClaimsXten*
    • No updates for August 2020.

    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.