Policy Updates February 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective February 15, 2017:
Breast Reconstruction Following Mastectomy or Lumpectomy - (0178) Modified
  • Important changes in coverage criteria:
    • Added coverage for DermACELL™ when used in association with medically necessary breast reconstruction procedures.
Invasive Treatments for Urinary Incontinence - (0365) Modified
  • Important changes in coverage criteria:
    • Added laser therapy to existing not covered policy statement.
Neuropsychological Testing - (0258) Modified
  • Important changes in coverage criteria effective February 9, 2017:
    • Added coverage for autism spectrum disorder, concussion, and mild cognitive impairment.
    • Clarified diagnoses and clinical scenarios when neuropsychological testing is not covered.
Omnibus Codes - (0504) Modified
  • Important changes in coverage criteria:
    • Added coverage for Insertion of Ocular Telescope Prosthesis Including Crystalline Lens:
      • CPT Code 0308T.
Plasmapheresis - (0153) Modified
  • Important changes in coverage criteria:
    • Added two diagnoses previously listed as covered to existing not covered policy statement:
      • Sydenham’s chorea (severe exacerbation),
      • Hemolytic uremic syndrome (HUS), atypical:
        • Changed name to thrombotic microangiopathy (TMA) coagulation, mediated.
      • Changes reflect 2016 update to the 2013 Guidelines on the Use of Therapeutic Apheresis in Clinical Practice from the American Society for Apheresis (ASFA).
Tissue-Engineered Skin Substitutes - (0068) Modified
  • Important changes in coverage criteria:
    • Added coverage for DermACELL™ when used in association with medically necessary breast reconstruction procedures.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy (drugs & biologics) coverage policies were modified effective February 15, 2017:
Unassigned Drug or Biologic Code Medical Precertification – (1701) New
  • Supports unassigned medical codes impacting EviCore Oncology management process, as well as potential expansion to support unassigned (non-J9999) code precertification.
  • Added Sustol (granisetron extended-release) criteria.
Denosumab (Prolia® and Xgeva®) - (1212) Modified
  • Important changes in coverage criteria:
    • Expanded diagnosis criteria for osteoporosis to align with American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) 2016 updated guidelines.
    • Updated criteria for Prolia in prostate cancer and Xgeva to align with recommendations from National Comprehensive Cancer Network (NCCN) guidelines.
    • Added criteria for Prolia and breast cancer that individual is at high risk for fractures.
    • Added criteria for Xgeva and Prolia in breast cancer:
      • No pre-existing hypocalcemia for all covered uses.
      • Individual is not pregnant.
Erythropoiesis Stimulating Agents (ESA) - (5016) Modified
  • Important changes in coverage criteria:
    • Added criteria for anemia associated with myelofibrosis for darbepoetin alfa and epoetin alfa.
Implantable Hormone Pellets - (1504) Modified
  • Important changes in coverage criteria:
    • Expanded diagnosis criteria for:
      • hypogonadism,
      • hypogonadotropic hypogonadism,
      • delayed puberty.
Interferon Therapy - (1315) Modified
  • Important changes in coverage criteria:
    • Reincorporated the FDA-approved condylomata acuminata indication to Intron A.
    • Added standard sample product note per coverage policy template.
    • Added Hepatitis E and Middle East respiratory syndrome to the experimental, investigational, or unproven (EIU) list.
Modafinil/Armodafinil (Provigil®/Nuvigil®) - (1501) Modified
  • Important changes in coverage criteria:
    • Added criteria for Individual and Family Plans to include a trial of generic versions of both products before approval of either brand name product.
Step Therapy – (1109) Modified
  • Important changes in coverage criteria:
    • Added gabapentin (Neurontin®) and Lyrica® (pregabalin) as step 1 agents in the Horizant B / Emerging Step Therapy to account for Horizant’s postherpetic neuralgia FDA-approved indication.
Testosterone undecanoate (Aveed®) - (1503) Modified
  • Important changes in coverage criteria:
    • Added appropriateness of use criteria for hypogonadism and hypogonadotropic hypogonadism by adding:
      • Documentation of signs and symptoms of androgen deficiency.
      • Two early morning, low total serum testosterone levels (below the testing laboratory's normal reference range) drawn on different days.
    • Removed criteria requiring failure, contraindication, or intolerance to a three-month trial of topical or generic injectable testosterone therapy.
Glucarpidase (Voraxaze®) - (1302) Retired
  • HCPCS code for glucarpidase moved to fast-certification status/no precertification required.
Radium Ra-223 dichloride (Xofigo®) - (1404) Retired
  • HCPCS code will be managed through EviCore Radiation Oncology guideline/program management criteria.
Policies Status Details
Administrative Policies
No updates for February 2017.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Twenty-one policies have been posted to the CareAllies Medical Necessity Guidelines(CAMNG).
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Policies Status Details
Precertification Policies*
Updates have been made to the following policies:
Medical Oncology Drugs Requiring Precertification New
Master Outpatient Precertification List Modified
Policies Status Details
Reimbursement Policies*
Updates have been made to the following policies:
R19 Hospital Acquired Conditions Modified
R25 Drug Testing Billing Requirements Modified
Modifier 47 Anesthesia by Surgeon Modified
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
No updates for February 2017.
Policies Status Details
Policies with a Reduction in Coverage
There were no additional policy updates for February 2017 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.