Policy Updates December 2016

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective December 15, 2016:
Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias – (0517) Modified
  • Important changes in coverage criteria:
    • Added coverage for confirmatory (diagnostic) genetic testing for a hereditary cardiomyopathy and/or arrhythmia.
Photodynamic Therapy for Dermatologic and Ocular Conditions - (0033) Retired
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Unless otherwise noted, the following coverage policies were modified effective December 15, 2016:
Filgrastim (Neupogen) – (1611) New
  • Effective date – January 1, 2017
  • Important changes in coverage criteria:
    • Supports the formulary change (preferred brand to non-preferred brand) and addition of prior authorization/medical precertification criteria.
Botulinum Therapy - (1106) Modified
  • Important changes in coverage criteria:
    • Added coverage of Dysport for blepharospasm.
    • Removed Botox requirement from Xeomin® for blepharospasm.
    • Updated initial authorization criteria (removed calcium channel blockers) for prevention of chronic migraine.
    • Updated reauthorization criteria (about decrease in headache duration) for prevention of chronic migraine.
    • Added coverage of Botox and Dysport for Hirschsprung disease.
    • Added coverage of Botox for interstitial cystitis as a fourth-line treatment.
    • Added bruxism as an experimental, investigational, or unproven (EIU) use.
Collagenase clostridium histolyticum (Xiaflex®) - (1021) Modified
  • Important changes in coverage criteria:
    • Updated criteria to include a maximum number of injections per cord in Dupuytren’s contracture.
    • Clarified degree of curvature deformity eligible for satisfaction of criteria in Peyronie’s disease.
    • Added standard non-coverage statement that all other uses are EIU.
Erythropoietin Stimulating Agents (ESA) - (5016) Modified
  • Important changes in coverage criteria:
    • Added coverage of Aranesp for anemia associated with myelodysplastic syndrome (MDS) and aligned criteria for Epogen/Procrit to Aranesp.
    • Added additional appropriate use criteria under myelosuppressive cancer chemotherapy-induced anemia for Epogen/Procrit and Aranesp.
PCSK9 Inhibitors - (1509) Modified
  • Important changes in coverage criteria:
    • Modified inadequate response to maximally tolerated lipid lowering therapy regimen criteria to include “not a candidate” for ezetimibe.
    • Clarified that lipid lowering therapy regimen consists of either high-intensity statin OR moderate- or low-intensity statin.
    • Removed the specialist prescriber requirement.
    • Added Repatha® PushtronexTM dosing for atherosclerotic cardiovascular disease/ heterozygous familial hypercholesterolemia.
Romiplostim (Nplate®) - (9002) Modified
  • Important changes in coverage criteria:
    • Clarified criteria to provide greater specificity about platelet levels required for approval.
    • Added reauthorization criteria to include demonstration of a continued need and benefit of therapy.
Policies Status Details
Administrative Policies
No updates for December 2016
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Thirteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
*Please log in to view these policies.
Policies Status Details
Precertification Policies*
No updates for December 2016
Policies Status Details
Reimbursement Policies*
Unless otherwise noted, the following policies were modified effective November 15, 2016:
Updated Policy Templates Modified
  • M25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
  • M26 – Professional Component
  • M27 – Multiple Outpatient Hospital Evaluation and Management Encounters on the Same Day
  • M50 – Bilateral Procedures
  • M51 – Multiple Procedures
  • M73 – Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia
  • M74 – Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After the Administration of Anesthesia
  • M99 – Multiple Modifiers
  • R03 – Multiple Births
  • R17 – Laboratory Services
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
No updates for December 2016
Policies Status Details
Policies with a Reduction in Coverage
There were no additional policy updates for December 2016 that resulted in a reduction of coverage.

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.