Policy Updates December 2018

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
There were no additional changes made in December 2018 that resulted in a reduction in coverage.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective December 15, 2018:
Cardiac Electrophysiological (EP) Studies – (0532) New
  • Originally provided advance notification on October 1, 2018; of new policy effective January 1, 2019.
Capsule Endoscopy – (0008) Modified
  • Important change in coverage criteria:
    • Clarified existing policy statement criteria.
Comparative Genomic Hybridization (CGH)/Chromosomal Microarray Analysis (CMA) for Selected Hereditary Conditions – (0493) Modified
  • Important changes in coverage criteria:
    • Updated title to reflect expanded policy scope.
    • Added coverage for CGH/CMA for known or suspected early infantile epileptic encephalopathy (onset before three years of age).
    • Added coverage for parental testing using CGH/CMA if a variant of unknown significance has been identified in a blood-related child.

Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds - (0004)

Modified
  • Important change in coverage criteria:
    • Added proprietary type of ESWT to existing not covered policy statement.
Home Blood Glucose Monitors - (0106) Modified
  • Important change in coverage criteria:
    • Added an experimental, investigation or unproven (EIU) statement for a new continuous glucose monitoring system with an implantable interstitial glucose sensor.
Infertility Services - (0089) Modified
  • Important change in coverage criteria:
    • Updated disclaimer language to clarify state mandates for coverage of fertility preservation services.
  • Important change in coverage criteria, effective December 15, 2018, posting January 1, 2019:
    • Clarified and simplified criteria.
  • Mechanical Devices for the Treatment of Back Pain - (0140) Modified
    • Important changes in coverage criteria:
      • Removed muscle testing policy statement and procedure codes:
        • Addressed in Physical Performance Test or Measurement – (CPG 295).
    Oral Cancer Screening Systems - (0372) Modified
    • Important changes in coverage criteria:
      • Removed tests that are no longer available.
    Pediatric Intensive Feeding Programs - (0422) Modified
    • Important changes in coverage criteria:
      • Clarified criteria; no change in coverage.
    Stretch Devices for Joint Stiffness and Contractures - (0135) Modified
    • Originally posted advance notification of important changes in coverage criteria on September 15, 2018, effective December 15, 2018:
      • Updated existing policy statements for low-load prolonged-duration stretch (LLPS) device/dynamic stretch device.
      • Updated policy statements for jaw stretch device.
    Varicose Vein Treatments - (0234) Modified
    • Important changes in coverage criteria:
      • Added endovenous catheter directed chemical ablation to existing EIU policy statement.
      • Simplified disclaimer language.
    Whole Exome and Whole Genome Sequencing – (0519) Modified
    • Important change in coverage criteria:
      • Added coverage for whole exome sequencing for a known or suspected early infantile epileptic encephalopathy (onset before three years of age) if other criteria are met.
    Policies Status Details
    Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)

    Physical Therapy – (CPG 135),

    Occupational Therapy – (CPG 155)

    Modified
    Policies Status Details
    Cigna-eviCore Cobranded Guidelines
    Modified
    • Updated Cigna-eviCore Comprehensive Musculoskeletal Management – (CMM 312) Knee Surgery Arthroscopic and Open:
      • Added clarification to MACI® Implant coverage criteria for “kissing lesions”.
    • Advance notification of updated Cigna-eviCore Imaging Guidelines, effective March 15, 2019:
      • Abdomen (both adult and pediatric guidelines)
      • Cardiac (both Adult and Pediatric guidelines)
      • Chest (both Adult and Pediatric guidelines)
      • Head (both Adult and Pediatric guidelines)
      • Musculoskeletal (both Adult and Pediatric guidelines)
      • Neck (both Adult and Pediatric guidelines)
      • Oncology (Adult only)
      • Pelvis (both Adult and Pediatric guidelines)
      • Peripheral Nerve Disorders (PND) (both Adult and Pediatric guidelines)
      • Peripheral Vascular Disease (PVD) (both Adult and Pediatric guidelines)
      • Spine (both Adult and Pediatric guidelines)
    Policies Status Details
    Administrative Policies
    Preventive Care Services - (A004) Modified
    • Important changes, effective December 1, 2018:
      • Updated screening services and coding table:
        • Abnormal Blood Glucose and Type 2 Diabetes Screening:
          • Added women with history of gestational diabetes mellitus.
          • Added Z86.32 to Wellness Code Group 1.
        • Osteoporosis Screening:
          • Updated reference to formal Clinical Risk Assessment Tool.
        • Routine Immunizations:
          • Added reference to Advisory Committee on Immunization Practices (ACIP) recommendations to Human Papillomavirus Vaccine age limits.
        • Urinary Incontinence Screening
          • Added to Preventive Services that may be provided during wellness exam.
    Policies Status Details
    Pharmacy (Drugs & Biologics) Policies
    The following pharmacy (drugs & biologics) coverage policies were modified effective December 15, 2018:
    Human Chorionic Gonadotropin (hCG) for Non-Fertility – (1815) New
    • Policy supports hCG precertification requirements for non-fertility uses in males.
    Botulinum Therapy - (1106) Modified
    • Important changes in coverage criteria:
      • Aligned chronic migraine criteria, where appropriate, with criteria found in Calcitonin Gene-Related Peptide (CGRP) Inhibitors – (1813).
      • Separated Sialorrhea criteria for cerebral palsy and Parkinsonism.
        • No change in criteria intent.
      • Added updated Xeomin interim criteria.
      • Added gastroparesis; nausea and vomiting, post-sleeve gastrectomy; pelvic floor spasm; and concurrent use, in chronic migraine, with a CGRP inhibitor as an unproven use to the EIU statement.

    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:
      • Updated Invokana criteria to address new indication for treatment of type II diabetes mellitus and established cardiovascular disease.
      • Added new available generic strength (55 mg) to Solodyn® criteria.
    Edaravone - (1806) Modified
    • Important changes in coverage criteria:
      • Added “Disease duration of 2 years or less” to initial criteria.
      • Expanded reauthorization criteria by more closely aligning it with initial criteria:
        • Documented diagnosis of amyotrophic lateral sclerosis (ALS) required.
    Eltrombopag – (9003) Modified
    • Important changes in coverage criteria:
      • Simplified severe aplastic anemia (SAA) criteria due to FDA expanded approval.
      • Clarified criteria stem language:
        • No change in criteria intent.
    Erythropoiesis Stimulating Agents (ESA) – (5016) Modified
    • Important changes in coverage criteria:
      • Added epoetin alfa-epbx (Retacrit) to criteria stem:
        • Removed Retacrit from the 180-day hold table.
        • Covered as preferred brand with specialty prior authorization.
        • Coverage criteria same as for Epogen and Procrit.
          • Changes effective December 1, 2018.
      • Reorganized format and clarified criteria stem language to include specific authorization intervals by anemia type:
        • No change in criteria intent.
    Hepatitis C – (1316) Modified
    • Important changes in coverage criteria:
      • Removed criteria for discontinued products:
        • Olysio
        • Technivie
        • Viekira XR
      • Removed language “commitment to participate in a hepatitis C disease state management program” from Hepatitis C Therapy coverage criteria.
      • Clarified Mavyret criteria stem language:
        • No change in criteria intent.
    Oncology Medications – (1403) Modified
    • Important changes in coverage criteria:
      • Added Lorbrena® and Talzenna to pharmacy benefit table.
      • Added Lumoxiti and Taxotere to medical benefit table.
      • Removed Docefrez (docetaxel) from medical benefit table:
        • Product discontinued.
    Oral Phosphodiesterase-5 (PDE5) Inhibitors – (7003) Modified
    • Important changes in coverage criteria:
      • Updated Employer group criteria to reflect preference of tadalafil and sildenafil before branded Viagra or Cialis approval for treatment of Raynaud’s disease.
      • Deleted “Note” under Erectile Dysfunction criteria discussing benign prostatic hypertrophy and erectile dysfunction combination treatment with Cialis.
    Romiplostim – (9002) Modified
    • Important changes in coverage criteria:
      • Added EIU uses listed in background to criteria stem EIU list.
      • Removed myelodysplastic syndrome (MDS) treatment use from uncovered use list.
    Tolvaptan - (P0056) Modified
    • Important changes in coverage criteria:
      • Corrected estimated glomerular filtration rate (eGFR) parameter criteria:
        • Should be greater than or equal to 25 ml/min/1.73m2;.
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    • One policy updated for December 15, 2018.
    • One policy updated for January 1, 2019.
    Policies Status Details
    Precertification Policies*
    The Master Precertification List was updated.
    Policies Status Details
    Reimbursement Policies*
    Policies Status Details
    ClaimsXten*
    No updates for December 2018

    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.