Policy Updates December 2019

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
Policies With a Reduction in Coverage
There were no additional changes made in December 2019 that resulted in a reduction in coverage.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective December 15, 2019:
Home Ventilators – (0546) New
  • Originally provided advance notification on September 15, 2019, effective January 1, 2020:
    • HCPCS code E0466 will be added to precertification.
      • HCPCS code E0467 already on precertification.
      • HCPCS code E0465 does not require precertification.
Site of Care: High-tech Radiology – (0550) New
  • Advance notification of new policy, effective March 27, 2020:
    • Based on standard of care.
    • eviCore will use to determine if an individual’s condition requires a hospital-based imaging department or facility versus a free-standing imaging facility.
    • Applies to the following high-tech imaging services:
      • Magnetic resonance imaging (MRI).
      • Magnetic resonance angiography (MRA).
      • Computed tomography (CT).
      • Computed tomography angiography (CTA).
Stem Cell Therapy for Orthopaedic Applications – (0552) New
  • Advance notification of new policy, effective March 15, 2020:
    • New experimental, investigational, or unproven (EIU) policy statement for stem cell therapy treatment of orthopaedic and/or musculoskeletal conditions.
  • Autism Spectrum Disorders/Pervasive Developmental Disorders: Assessment and Treatment - (0447) Modified
    • Important change in coverage criteria:
      • Added blood metabolite testing to existing EIU policy statement (e.g., NeuroPointDX Autism Spectrum Disorder).
        • New 2020 CPT code - 0139U.
    Benign Prostatic Hyperplasia (BPH) Treatments - (0159) Modified
    • Important change in coverage criteria:
      • Added coverage policy statement for water vapor thermal therapy (e.g., Rezum System).
    Cochlear and Auditory Brainstem Implants - (0190) Modified
    • Important changes in coverage criteria:
      • Added coverage for individuals less than 12 months of age.
      • Added coverage for cochlear implant for single-sided deafness.
    Comparative Genomic Hybridization Testing (Chromosomal Microarray Analysis) for Autism Spectrum Disorders, Developmental Delay, Intellectual Disability and Multiple Congenital Anomalies - (0493) Modified
    • Important change in coverage criteria:
      • Removed requirement for genetic counseling (GC).
        • GC is now only recommended.
    Genetic Expression Profiles for Detection of Heart Transplantation Rejection (e.g., AlloMap®) - (0465) Modified
    • Minor changes in criteria/policy:
      • Added clarifications in policy statement.
    Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias – (0517) Modified
    • Important changes in coverage criteria:
      • Added criteria for genetic testing (GT) to identify familial variants in an individual with a diagnosis may have clinical utility.
      • Removed left ventricular non-compaction (LVNC) as a medically necessary indication for testing:
        • Based on new practice statements from the Heart Failure Society of America.
      • Revised policy statement for GT for dilated cardiomyopathy (DCM) to reflect testing using a targeted panel may be clinically useful.
    Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514) Modified
    • Important changes in coverage criteria:
      • Updated criteria for Fragile X testing to reflect female parent.
      • Removed “23” as the number of CTFR gene variants for which testing is considered medically necessary.
      • Added criteria that a targeted panel testing for Ashkenazi Jewish disorders is considered medically necessary.
      • Updated policy statement to reflect sequencing-based screening tests are considered not medically necessary to determine nonmedical traits (e.g., biologic sex).
      • Updated criteria for prenatal testing of a fetus when abnormal findings are identified on ultrasound.
      • Added criteria noting that Comparative Genomic Hybridization (CGH)/Chromosomal Microarray Analysis (CMA) on products of conception is considered medically necessary when conventional karyotyping has failed.
    Hyperthermic Intraperitoneal Chemotherapy (HIPEC) - (0396) Modified
    • Important change in coverage criteria:
      • Added coverage statement for stage III epithelial ovarian cancer to be consistent with National Comprehensive Cancer Network (NCCN).
    Intensive Behavioral Interventions - (0499) Modified
    • Minor change in coverage criteria/policy:
      • Added minor clarifications in policy statement.
    Intestinal and Multivisceral Transplantation - (0288) Modified
    • Important change in coverage criteria:
      • Removed EIU policy statement on living donor intestinal or multivisceral transplantation.
    Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, Including Sacroiliac Fusion - (0303) Modified
    • Important changes in coverage criteria:
      • Added policy statement for coverage of percutaneous sacroiliac (SI) joint fusion.
      • Added open sacroiliac joint fusion criteria to existing EIU policy statement.
    Nucleic Acid Pathogen Testing – (0530) Modified
    • Important changes in coverage criteria:
      • Updated criteria for candida:
        • Added additional indications.
    Speech Therapy - (0177) Modified
    • Important changes in coverage criteria:
      • Separated sections for speech/language therapy and voice therapy.
      • Added section for aural/auditory rehabilitation.
      • Removed evaluation section.
      • Clarified speech language section.
      • Clarified voice therapy section.
      • Clarified criteria in the continuation of therapy sections in speech and voice therapy.
      • Clarified language and included auditory/aural rehabilitation for presbycusis in the not medically necessary section.
      • Added appendix in the background for documentation requirements for speech therapy.
    Stem Cell Transplantation: Non-Cancer Disorders – (0535) Modified
    • Important changes in coverage criteria:
      • Added policy statement covering autologous hematopoietic stem cell transplantation (HSCT) for a subset of individuals with multiple sclerosis (MS) and systemic sclerosis (scleroderma).
    Temporomandibular Joint (TMJ) Disorder Surgery - (0156) Modified
    • Important changes in coverage criteria:
      •  Added coverage of all FDA-approved TMJ prosthetic devices, including total and partial joint devices.
    Transcatheter Heart Valve Procedures - (0501) Modified
    • Important changes in coverage criteria:
      • Added coverage policy statement for transcatheter aortic valve replacement (TAVR) in low surgical risk patients.
      • Added cerebral protection devices (e.g., Sentinel™ Cerebral Protection System) to existing EIU policy statement.
    Vagus Nerve Stimulation (VNS) - (0350) Modified
    • Important change in coverage criteria:
      • Clarified replacement/revision policy statement.
    Ventricular Assist Devices (VADs), Percutaneous Cardiac Support Systems and Total Artificial Heart – (0054) Modified
    • Important changes in coverage criteria:
      • Updated title.
      • Added content from Total Artificial Heart – (0281); which will be retired.
      • Added Impella 5.5 to existing percutaneous VADs policy statement.
    Vision Therapy/Orthoptics - (0221) Modified
    • Minor changes in coverage criteria/policy:
      • Added content from Visual Perceptual Training (VPT) – (0410); which will be retired.
        • No change in coverage.
        • VPT remains EIU for all indications.
    Capsule Endoscopy – (0008) Retired
    Total Artificial Heart - (0281) Retired
    Visual Perceptual Training (VPT) – (0410) Retired
    Policies Status Details
    American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
    Updated Physical Therapy – (CPG 135) Modified
    • Updated existing EIU policy statement:
      • Added interactive metronome program.
      • Added high-power class IV therapeutic laser light therapy.
    Updated Occupational Therapy – (CPG 155) Modified
    • Added interactive metronome program to existing EIU statement.
    Policies Status Details
    Cigna-eviCore Cobranded Guidelines
    High-Tech Radiology (HTR or Imaging) guidelines New
    Policies Status Details
    Administrative Policies
    • No updates for December 2019
    Policies Status Details
    Pharmacy (Drugs & Biologics) Policies
    Unless otherwise noted, the following pharmacy coverage policies were modified effective December 1, 2019:
    Caplacizumab-yhdp – (1906) New
    • Supports medical precertification requirements.
    Triclabendazole – (P0105) New
    • Supports pharmacy rior authorization requirements
    Antiemetic Therapy – (1705) Modified
    • Important changes in coverage criteria:
      • Added coverage criteria for:
        • Marinol
        • Syndros
        • Zofran
        • Zofran ODT
        • Zuplenz
          • Removed criteria for the above from coverage policies 1601 and 1602.
          • Covered only when medical necessity criteria are met.
      • Added criterion requiring an embedded step through generic fosaprepitant dimeglumine 150 mg vial to brand Emend injection.
        • Generic aprepitant product required first as part of business decision for Emend coverage.
        • Emend already requires prior authorization, is primarily medical benefit IV, will require A-rated generic before brand Emend.
      • Removed specific coverage criteria language for generic Aloxi formulation, palonosetron:
        • Generic formulation carries approved FDA indication for use in pediatric individuals aged 1 month to less than 17 years for prevention of nausea and vomiting associate with initial and repeat courses of emetogenic cancer chemotherapy.
        • Coverage criteria for the generic formulation follows criteria for the brand formulation.
      • Removed Varubi injectable formulation including information pertaining to the product’s suspended distribution from coverage criteria stem.
        • Product discontinued March 2018.
      • Removed Anzemet (dolasetron) as a formulary alternative from Zofran criteria:
        • Anzemet has not been/is not available in the marketplace.
      • Reorganized coverage criteria for Aloxi (palonosetron) injection.
        • No change to criteria intent.
    Belimumab – (1114) Modified
    • Important changes in coverage criteria:
      • Revised age to five years of age due to expanded indication:
        • Label down to five years of age for IV formulation; but SME recommendation was to use this age for both formulations so as not to require a pediatric patient to use IV formulation.
      • Added bullet that standard therapy must use be concurrently with Benlysta:
        • Based on FDA label support and European League Against Rheumatism (EULAR) 2019 guidelines that state recommendation as add-on therapy.
      • Removed requirement of no evidence of severe active lupus nephritis and severe active central nervous system lupus:
        • Moved to EIU section.
      • Removed requirement that patient is not using Benlysta in combination with a biological DMARD, such as tumor necrosis factor:
        • Moved to EIU section.
      • Added requirement that the agent must be prescribed or in consultation with a specialist, such as a rheumatologist.
      • Added reauthorization criteria requiring that initial use criteria are met and that the individual is responding to treatment.
    Botulinum Therapy - (1106) Modified
    • Important changes in coverage criteria:
      • Added a specialist prescribing requirement for each covered indication.
      • Expanded Myobloc coverage to include chronic sialorrhea:
        • Responsive to FDA label expansion.
      • Added reauthorization criteria and reauthorization time limit of 12 months.
      • Added plantar hyperhidrosis and trigeminal neuralgia to EIU criteria section.
    Cannabidiol - (1814) Modified
    • Important changes in coverage criteria:
      • Added requirement of failure of at least one antiepileptic drug, before Epidiolex.
      • Added requirement for Epidiolex to be used concurrently with at least one other antiepileptic drug.
      • Added initial and reauthorization time limits of 12 months and reauthorization criteria.
    Calcitonin Gene-Related Peptide (CGRP) Inhibitors - (1813) Modified
    • Important changes in coverage criteria:
      • Updated the “no concurrent use with other CGRP inhibitors” statements to clarify the criteria intent.
      • Removed no concurrent use with Botox criteria statement:
        • Moved to EIU statement.
      • Added Emgality cluster headache criteria:
        • Based on expanded FDA approved indication.
      • Added reauthorization time limit of 12 months
    Etelcalcetide – (1812) Modified
    • Important changes in coverage criteria:
      • Added initial and reauthorization duration of 12 months.
      • Added reauthorization criteria requiring initial criteria were met at the start of therapy and no concurrent use with cinacalcet.
      • Changed formatting to current criteria template with no clinical change.
    Lomitapide Mesylate – (1507) Modified
    • Important changes in coverage criteria:
      • Removed mipomersen (Kynamro):
        • No longer available; discontinued by manufacturer.
      • Expanded EIU section with specific examples.
    Mifepristone (Korlym) – (P0021) Modified
    • Important changes in coverage criteria:
      • Added age limitation to 18 years and older:
        • Aligns with FDA labeled indication.
      • Modified minor wording within criteria for added clarity and ease of reading/interpretation.
      • Added additional “documented response to therapy” statement to reauthorization criteria.
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    • No updates for December 2019
    Policies Status Details
    Precertification Policies*
    Policies Status Details
    Reimbursement Policies*
    One Reimbursement Policy updated:
    Evaluation and Management Services – (R30) Modified
    • Policy was updated.
    Policies Status Details
    ClaimsXten*
    No updates for December 2019

    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.