Policy Updates December 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective December 15, 2017:
Vitamin D Testing - (0526) New
  • Advance posting December 15, 2017 of policy effective March 15, 2018:
    • Supports serum Vitamin D testing.
      • Will be implemented with a procedure-to-diagnosis (PXDX) edit on CPT codes 82306 and 82652, allowing payment for certain diagnoses only.
        • All other diagnosis codes will be denied as not medically necessary (NMN).
        • Will not apply to ages 17 and under, 65 and older, and pregnant women.
Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment - (0447) Modified
  • Important changes in coverage criteria, effective January 1, 2018:
    • Removed “intensive behavioral interventions for autism” from the NMN treatment policy statement.
    • Additional changes - not a change in coverage:
      • Updated disclaimer section about state mandates and services that are training in nature.
      • Removed references to the Cigna Behavioral Health medical necessity criteria for Applied Behavior Analysis (ABA).
Continuous Passive Motion (CPM) Devices - (0198) Modified
  • Advance posting on December 15, 2017; updates effective March 15, 2018:
    • Changed from covered to not covered following knee replacement.
      • Turned off PXDX edit that allows for E0935 (CPM knee) with ICD10 codes Z96.651-Z96.659 (Presence of artificial knee joint).
      • Moved E0935 to always experimental, investigational or unproven (EIU) for all diagnosis codes.
    • No change to E0936 (CPM other than knee):
      • Remains always EIU for all diagnosis codes.
Intensive Behavioral Interventions – (0499) Modified
  • Important change in coverage criteria, effective January 1, 2018:
    • Changed ABA treatment from not covered to covered when specific criteria are met.
Oxygen for Home Use – (0207) Modified
  • Important update,no change in coverage criteria:
    • Added clarifying statement about oxygen delivery service.
Treatment of Gender Dysphoria – (0266) Modified
  • Important change in coverage criteria:
    • Added coverage of nipple/areola reconstruction post-mastectomy per Federal mandate for female to male transition.
Physical Therapy – (0096) Retired
  • Will be retired effective January 1, 2018.
  • Replaced by Cigna-American Specialty Health (ASH) cobranded Clinical Practice Guidelines Physical Therapy - (CPG135).
Occupation Therapy – (0232) Retired
  • Will be retired effective January 1, 2018.
  • Replaced by Cigna-American Specialty Health (ASH) cobranded Clinical Practice Guidelines Occupational Therapy - (CPG155).
Policies Status Details
Cigna-ASH Coverage Policy Guidelines
Cobranding process includes clarification of intent of coverage and no change in actual coverage. Advance notification of important changes, effective January 1, 2018:
Physical Therapy – (0096) Retired
  • Replaced by new Cigna-ASH cobranded guideline Physical Therapy - (CPG135)
Occupational Therapy – (0232) Retired
  • Replaced by new Cigna-ASH cobranded guideline Occupational Therapy - (CPG155)
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Advance notification of important changes in coverage criteria, effective March 1, 2018:
Modified
  • Expanded coverage in eight guidelines to be consistent with NCCN recommendations, American Society for Radiation Oncology (ASTRO), and/or current evidence-based literature.
  • Expanded radiation therapy for non-malignant conditions to be more comprehensive and inclusive of requests eviCore receives.
  • Added coverage of IORT for breast cancer for a subset of patients as recommended by NCCN and ASTRO.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective December 15, 2017:
Dose Optimization - (1804) New
  • Policy supports medical necessity review for products included in the “Dose Optimization” program, formerly known as DACON.
    • Includes active DACON products and new products to the program.
Immunomodulators – (1805) New
  • The following coverage policies and associated criteria for both Employer Group Benefit Plans and Individual and Family Benefit Plans are included in this new policy:
    • Abatacept – (6112)
    • Anakinra – (4063)
    • Anti-Tumor Necrosis Factor Therapy -(9014)
    • Interleukin 12/23 and 17 - (1017)
    • Natalizumab for Crohn’s Disease – (6017)
    • Tofacitinib– (1410)
    • Tocilizumab – (1024)
    • Vedolizumab – (1502)
  • Added criteria for:
    • Kevzara (sarilumab)
    • Tremfya (guselkumab)
    • Renflexis (infliximab-abda)
  • Revised criteria for business decision changes for Individual and Family Plans only:
    • Added details for early customer access for Actemra and Cosentxy
    • Added Actemra step for rheumatoid arthritis and Cosentyx step for psoriasis/psoriatic arthritis for non-preferred or non-formulary immunomodulators.
  • Note - the links above for the new coverage policies 1804 and 1805 will not be active until Janaury 1, 2018.
  • Eltrombopag - (9003) Modified
    • Important change in coverage criteria:
      • Added reauthorization criteria.
    Erythropoiesis Stimulating Agents (ESA) - (5016) Modified
    • Important changes in coverage criteria:
      • Removed criteria requiring all other causes of anemia are ruled out or corrected.
      • Removed criteria that individual does not have the presence of a contraindication to therapy.
      • Added definition of adequate iron stores.
      • Added additional EIU uses.
    Hepatitis C Therapy - (1316) Modified
    • Important changes in coverage criteria:
      • Added Vosevi®:
        • Criteria align to FDA-approved indications and recommended uses per American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA).
    The following drugs & biologics coverage policies were modified effective January 1, 2018:
    Antiemetic Therapy - (1705) Modified
    • Important changes in coverage criteria:
      • Added coverage criteria to support medical precertification of Aloxi® and Emend injection and pharmacy prior authorization of Akynzeo®, Anzemet, Emend oral, Sancuso®, and Varubi.
        • Aligned coverage criteria to National Comprehensive Cancer Network (NCCN) recommended uses.
        • Emend oral criteria also require use of generic capsules.
    Apremilast - (1414) Modified
    • Important changes in coverage criteria:
      • Added Otezla to all formularies resulting in the following changes:
        • Changed number of anti-TNFs required from two to none for plaque psoriasis.
        • Changed number of anti-TNFs required from two to one for psoriatic arthritis.
    Controlled Substance Analgesic and Narcotic Antagonist Quantity Limitations - (1706) Modified
    • Important changes in coverage criteria:
      • Decreased quantity limit for liquid cough combinations to 240 mL (from 480 mL or 960 mL) per 30 days.
      • Removed Xartemis XR:
        • Product discontinued.
    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 multiple drugs and biologics consistent with the general criteria approach outlined below:
        • Drugs or biologics with a significantly higher cost compared to their therapeutic alternatives (where all other clinical factors are the same):
          • Maximum of five therapeutic alternatives required.
        • Multisource brand drugs:
          • Alternatives include generic equivalents, as well as therapeutic alternatives.
        • Single-source combination products:
          • Alternatives include the individual components taken separately.
        • Non-preferred products:
          • Alternatives limited to the preferred product(s).
    Modafinil/Armodafinil - (1501) Modified
    • Important changes in coverage criteria:
      • Added criteria for brand name Nuvigil and Provigil requiring use of generic products first for Employer Groups.
      • Removed trade names from title.
    Multiple Sclerosis Therapy - (1402) Modified
    • Important changes in coverage criteria:
      • Added medical precertification criteria for Ocrevus (ocrelizumab).
      • Added medical necessity criteria for Glatopa for Individual and Family Plans.
    Oncology Medications - (1403) Modified
    • Important changes in coverage criteria:
      • Added specific criteria for the following:
        • Chronic Myeloid Leukemia (CML) Initial Therapy for Chronic Phase:
          • Gleevec (imatinib), Sprycel®, Tasigna®
        • Chronic Myeloid Leukemia (CML) Second-Line or Subsequent Therapy for Chronic Phase:
          • Bosulif®, Iclusig®, Sprycel, Tasigna
        • Nilandron (not covered on Employer Group Benefit Plans and Individual & Family Benefit Plans)
        • Kymriah (tisagenlecleucel)
      • Added numerous injectable drugs to the medical benefit table.
      • Added Calquence® (acalabrutinib) to pharmacy benefit table.
    Opioid Therapy - (1704) Modified
    • Important changes in coverage criteria:
      • Added medical necessity criteria for Roxicodone.
      • Moved Embeda to preferred brand
      • Moved OxyContin to non-formulary:
        • Not covered unless approved by medical necessity review.
      • Updated extended-release criteria:
        • Business decision to require all preferred brands before a non-preferred brand
        • Diagnosis exceptions (active cancer treatment, end-of-life care or sickle cell disease) will not apply.
      • Removed Xartemis XR:
        • Product discontinued.
    Pharmacy Prior Authorization - (1407) Modified
    • Important changes in coverage criteria:
      • Removed criteria for Basaglar (insulin glargine).
      • Added criteria for Lantus and Toujeo (insulin glargine).
      • Added criteria for Zurampic and Dificid®.
      • Added table for Therapeutic Categories requiring Prior Authorization:
        • Includes skin conditions and drugs categorized as narrow therapeutic index.
    Quantity Limitations – (1201) Modified
    • Important changes in coverage criteria:
      • Added several products at twice the FDA-recommended dosing limitations.
      • Removed Zequity:
        • Product discontinued.
    Step Therapy – (1109) Modified
    • Important changes in coverage criteria:
      • Attention Deficit Hyperactivity Disorder:
        • Moved Focalin XR from Step 2 to Step 3.
        • Added Cotempla XR-ODT and Mydayis to Step 3.
      • Atypical Antipsychotics:
        • Added Aripiprazole and pimozide to Step 1.
        • Added Abilify and Orap added to Step 3.
      • Insomnia:
        • Moved Silenor® from Step 2 to Step 3.
      • Long-Acting Opioids:
        • Moved Embeda from Step 3 to Step 2.
        • Moved OxyContin moved from Step 2 to Step 3.
      • Nasal Steroids:
        • Added Xhance to Step 3.
      • Topical Inflammatory:
        • Divided into four categories of potency.
        • Removed Elidel®, Protopic, and tacrolimus.
      • Emerging Drug Therapy:
        • SGLT2:
          • Removed class from Step Therapy.
          • Jardiance, Synjardy/XR added as preferred brand.
        • Topical Testosterone:
          • Removed class from Step Therapy.
          • Prior authorization will be required.
        • Carvedilol/ER added as Step 1.
        • Lialda moved from Step 1 to Step 2.
        • Generic mesalamine DR 1.2 gm added to Step 1.
    Step Therapy Individual and Family Plans – (1603) Modified
    • Important changes in coverage criteria:
      • Attention Deficit Hyperactivity Disorder:
        • Removed Adderall XR from Step 2.
        • Added criteria for Vyvanse for use for a diagnosis of binge-eating disorder (BED) without step therapy requirements.
      • Angiotensin Receptor Blocker:
        • Removed Benicar and Benicar HCT from Step 2.
      • Glucagon-like peptide 1 (GLP1) Inhibitors:
        • Added Bydureon® BCiseTM to Step 1.
      • Removed long-acting insulin class.
      • Long-Acting Beta Agonist:
        • Removed Foradil from Step 2.
      • Selective serotonin reuptake inhibitor (SSRI), Selective Serotonin-norepinephrine reuptake inhibitor (SSNRI):
        • Added desvenlafaxine ER to Step 1
      • Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors:
        • Added criteria for Jardiance for use for a diagnosis of both Type 2 diabetes and cardiovascular disease without step therapy requirements.
      • Statins:
        • Added ezetimibe/simvastatin to Step 1.
    Testosterone Therapy - (1503) Modified
    • Important changes in coverage criteria:
      • Added prior authorization requirement for all topical testosterone products.
      • Added requirement of generic testosterone gel AND preferred brand, AndroGel before non-preferred brand or non-formulary products:
        • Axiron, Fortesta®, Natesto, Testim and Vogelxo.
      • Expanded definition of low serum testosterone level from below the laboratory’s normal reference range to include an option of specific values.
      • Changed title from Testosterone undecanoate (Aveed) to Testosterone Therapy
    Policies Status Details
    Administrative Policies
    No updates in December 2017.
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    Various Modified Twelve policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG)
    *Please log in to view these policies.
    Policies Status Details
    Precertification Policies*
    Updates have been made to the following:
    Changes to Precertification List Effective January 2018 Modified
    Policies Status Details
    Reimbursement Policies*
    Updates have been made to the following policies:
    R12 - Facility Routine Services, Supplies and Equipment Modified
    R23 - Global Surgical Packages and Related Modifiers Policy Modified
    R24 - Omnibus Reimbursement Policy Modified
    MAS - Assistant Surgeon – Modifiers 80, 81, 82; Assistant-at-Surgery–Modifier AS; Co-Surgeon (Two Surgeons) – Modifier 62; Surgical Team – Modifier 66 Modified
    Modifier MRG - Modifier Reference Guide Modified
    Policies Status Details
    Claim Editing Policies and Procedures* ClaimsXten
    No updates for December 2017
    Policies Status Details
    Policies with a Reduction in Coverage
    There were no additional changes made in December 2017 that resulted in a reduction in 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.