Policy Updates December 2015

Policies Status Details
Medical Coverage Policy
Electroencephalography – (0521) New
  • Policy posted December 30, 2015, but not effective until March 15, 2016.
  • Contains information about ambulatory electroencephalography (EEG) and EEG digital spike analysis.
  • Important changes in coverage:
    • Changed ambulatory electroencephalography (EEG) and EEG digital spike analysis from covered to not covered when specific criteria are not met.
      • Both services currently allowed without restriction
      • Implementation lever will be procedure to diagnosis for ambulatory EEG; and procedure to procedure for EEG digital spike analysis
Miscellaneous Musculoskeletal Procedures – (0515) New
  • Policy posted on December 15, 2015, but not effective until January 1, 2016.
  • Consolidates four coverage policies:
    • Allograft Transplantation of the Knee - (0071)
    • Chondrocyte Implantation of the Knee - (0105)
    • Knee Replacement/Arthroplasty - (0347)
    • Osteochondral Grafting for Articular Cartilage Defects (Autograft, Allograft, Synthetic) - (0197)
  • Policy statement update with no change in coverage:
    • Changed denial rationale for preoperative imaging for knee replacement procedures from experimental, investigational, unproven (EIU) to not medically necessary.
Deep Brain, Motor Cortex and Responsive Cortical Stimulation - (0184) Modified
  • Important change in coverage
    • Changed responsive cortical stimulation in a specific subgroup of patients with medically refractory partial seizures from not covered to covered.
Drug Testing – (0513) Modified
  • Important changes in coverage:
    • Changed definitive drug testing from not covered to covered when results of presumptive testing are inconsistent with the patient's condition, history, and examination.
      • Previously, presumptive drug testing results had to be positive before definitive testing was covered.
    • Updated criteria noting testing can be done in any physician-supervised treatment setting, rather than just limited to an addiction or pain management setting.
  • Policy statement update with no change in coverage:
    • Added wording "16 dates of service" to clarify frequency of definitive drug testing.
Implantable Infusion Pump for Non-Musculoskeletal Conditions – (0370) Modified
  • Important change in coverage:
    • Removed musculoskeletal-related policy statements and content that will now be managed by eviCore healthcare.
  • Policy statement update with no change in coverage:
    • Changed title from Implantable Infusion Pumps to Implantable Infusion Pump for Non-Musculoskeletal Conditions.
Minimally Invasive Intradiscal/Annular Procedures and Trigger Point Injections – (0139) Modified
  • Important change in coverage:
    • Removed musculoskeletal-related policy statements and content that will now be managed by eviCore.
  • Policy statement update with no change in coverage:
    • Changed title from Minimally Invasive Treatment of Back and Neck Pain to Minimally Invasive Intradiscal/Annular Procedures and Trigger Point Injections
Pediatric Intensive Feeding Programs – (0422) Modified
  • Important change in coverage:
    • Changed outpatient pediatric intensive multidisciplinary feeding program from not covered to covered.
Prostate-Specific Antigen (PSA) Screening for Prostate Cancer – (0215) Modified
  • Policy statement update with no change in coverage:
    • Added statement about informed decision.
Rhinoplasty, Vestibular Stenosis Repair and Septoplasty – (0119) Modified
  • Important change in coverage:
    • Removed some specific requirements from existing coverage criteria
Allograft Transplantation of the Knee - (0071) Retired Content incorporated in the new Miscellaneous Musculoskeletal Procedures - (0515) medical coverage policy.
Chondrocyte Implantation of the Knee - (0105) Retired Content incorporated in the new Miscellaneous Musculoskeletal Procedures - (0515) medical coverage policy.
Electrophysiological 3-Dimensional Mapping – (0074) Retired This policy will also be retired.
Hip Surgery for Femoroacetabular Impingement (FAI) Syndrome – (0485) Retired
Knee Replacement/Arthroplasty - (0347) Retired Content incorporated in the new Miscellaneous Musculoskeletal Procedures - (0515) medical coverage policy.
Magnetoencephalography – (0248) Retired This policy will also be retired.
Osteochondral Grafting for Articular Cartilage Defects (Autograft, Allograft, Synthetic) - (0197) Retired Content incorporated in the new Miscellaneous Musculoskeletal Procedures - (0515) medical coverage policy.
Spinal Cord and Implanted Peripheral Nerve Stimulation – (0380) Retired
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
PCSK9 Inhibitors – (1509) New
  • Created to support pharmacy benefit prior authorization for PCSK9 Inhibitor therapy.
Clotting Factors and Antithrombin – (8007) Modified
  • Important change in coverage:
    • Added Nuwiq®, a newly FDA approved antihemophilic factor (recombinant).
Eltrombopag (Promacta®) – (9003) Modified
  • Important changes in coverage:
    • Expanded criteria to align with newly FDA approved indication (individuals one year of age and older).
    • Clarified criteria about insufficient response to note initial therapy with corticosteroids and IVIG
Erythropoietin Stimulating Agents (ESA) – (5016) Modified
  • Important change in coverage:
    • Added methoxy polyethylene glycol-epoetin beta (Mircera®), a newly FDA approved erythropoietin stimulating agent
Lysosomal Storage Disorder Therapy – (1319) Modified
  • Important change in coverage:
    • Added asfotase alfa (Strensiq), a newly FDA approved lysosomal storage disorder therapy
Pharmacy Prior Authorization – (1407) Modified
    • Important update with no change in coverage:
      • Added content about Rilonacept (Arcalyst)
      • Retired Rilonacept (Arcalyst) coverage policy as stand-alone policy
Romiplostim (Nplate®) – (9002) Modified
  • Important change in coverage:
    • Clarified criteria about insufficient response to note initial therapy with corticosteroids and IVIG
Rilonacept (Arcalyst) –(8011) Modified
Policies Status Details
Administrative Policies
There were no administrative policy updates for December.
Policies Status Details
CareAllies Medical Necessity Guidelines
Updates Thirteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
Policies Status Details
Reimbursement Policies*
There were no reimbursement policy updates for December.
Policies Status Details
Claim Editing Policies and Procedures ClaimsXten
Code Edit Bulletin - February 2016 Modified
  • Important changes effective February 13, 2016:
    • Adopting CMS guidelines and implementing a Medically Unlikely Edit (MUE) for CPT code 86160, Complement; antigen, each component using ClaimsXten.
    • Frequency limit of four units will be applied.
Policies Status Details
Policies with a Reduction in Coverage**
Allergy Testing and Non-Pharmacologic Treatment Modified

Consistent with Centers for Medicare & Medicaid Services (CMS) guidelines, industry standards, and our current Allergy Testing and Non-Pharmacologic Treatment coverage policy, we will apply a daily frequency limit of four units to complement antigen testing (CPT® code 86160).*

* This update was implemented in Texas on January 1, 2016

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.

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** The following policy updates, effective December 15, 2015, will result in a reduction of coverage.