Policy Updates February 2018

Important New 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 Details
Policies with a Reduction in Coverage
We are changing how we reimburse for the following policies for claims processed or dates of service on or after February 19, 2018.

R12 Facility Routine Services, Supplies, and Equipment Policy *

Intraoperative Neurophysiological Monitoring (IONM) – (0509)

  • We will update our R12 Facility Routine Services, Supplies, and Equipment Policy and deny claims for IONM services, and other electrodiagnostic studies when billed with IONM services, as not separately reimbursable.
  • IONM services, and other electrodiagnostic studies are included in the facility reimbursement.

Peripheral Nerve Destruction for Pain Conditions (0525)

Headache and Occipital Neuralgia Treatment (0063)

Radiofrequency Joint Ablations/Denervation (CMM 208)

Plantar Fasciitis Treatments (0097)

  • We will create a new coverage policy for Peripheral Nerve Destruction for Pain Conditions (0525) for knee, foot, and ankle pain.
  • We will update coverage policies for Occipital Neuralgia and Headaches (0063), Radiofrequency Joint Ablations/Denervation (CMM 208), and Plantar Fasciitis (0097).
  • Claims for peripheral nerve destruction for pain conditions billed with CPT codes 64632 and 64640 will be denied as being experimental, investigational, and unproven (EIU).

MAS - Modifiers 62, 66, 80, 81, 82, and AS Assistant Surgeon, Assistant at Surgery, Co-Surgeon (Two Surgeons), and Surgical Team *

  • We will enhance our processes to ensure that we reimburse primary, assistant, and co-surgeons consistently.
  • We will reimburse the first claim we receive and reimburse or deny any additional claims as appropriate, based on how the first claim was processed.

Global Surgical Package and Related Modifiers (24, 54, 55, 56, 57, 58, 76, 77, 78, and 79) *

  • We will update our policy and reimburse Modifier 78 at 70 percent.

Omnibus Reimbursement Policy (R24) *

A4566 Electrodes Per Pair Frequency Limit

  • We will update our Omnibus Reimbursement Policy (R24) policy and implement a frequency limit of 48 units (or pairs) of electrodes per year.

Pneumatic Compression Devices and Compression Garments (0354)

  • We will update our policy and deny claims when R60.0 is billed alone or with other diagnosis codes that are not covered because compression devices are not indicated for use for localized edema.
  • We will deny claims billed with E0675 in a home setting for all diagnoses as being EIU.

Omnibus Reimbursement Policy (R24) *

Outpatient UB -Clinic Not Covered

  • We will deny claims for clinic room charges billed with Revenue Codes 510-515, 517-525, and 527-529 when the claim also includes Evaluation & Management (E&M) code(s) for an office visit.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective February 15, 2018:
Peripheral Nerve Destruction for Pain Conditions – (0525) New
  • Advance notification provided November 15, 2017 for policy effective February 15, 2018:
    • Implemented with a procedure-to-diagnosis (PXDX) edit on CPT codes 64640 and 64632 when billed with certain pain conditions.
    • Includes coverage policy statement for peripheral nerve destruction for treatment of trigeminal neuralgia refractory to other alternative treatments.
      • No change in coverage (not part of new edit).
Bone, Cartilage and Ligament Graft Substitutes – (0118) Modified

Drug Testing – (0513)

Modified
  • Important change in coverage criteriafor all of the policies listed:
    • Added specimen validation by buccal swab to existing policy statement.
      • No change in coverage.
Headache and Occipital Neuralgia Treatment - (0063) Modified
Plantar Fasciitis Treatments – (0097) Modified
Pneumatic Compression Devices and Compression Garments - (0354) Modified
  • Advance notification provided November 15, 2017 for important changes to coverage criteria effective February 15, 2018:
    • Changed pneumatic pumps for edema from covered to not covered.
    • Removed “refractory edema” from existing covered policy statement.
    • Removed ICD10 code R60.0 (localized edema) from covered diagnosis codes.
    • Changed pneumatic pumps in the home setting for arterial insufficiency from covered to not covered.
    • Added “a pump for arterial insufficiency (HCPCS code E0675)” to existing not covered policy statement.
      • Code E0675 will have an “Always Experimental, Investigational or Unproven (EIU)” edit.
Ventricular Assist Devices (VADs) and Percutaneous Cardiac Support Systems – (0054) Modified
  • Important change in coverage criteria:
    • Updated percutaneous Ventricular Assist Devices (VADs) policy statement.
Chiropractic Care – (0267) Retired
Policies Status Details
Cigna-ASH Coverage Policy Guidelines
Chiropractic Care – (CPG287) New
  • Retired Cigna Coverage Policy Chiropractic Care - (0267).
  • Cobranding process includes clarification of intent of coverage and no change in actual coverage.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
  • No updates for February 2018.
Policies Status Details
Administrative Policies
Preventive Care Services – (A004) Modified
  • Updated screening services and coding table:
    • Female contraception counseling:
      • Added instruction in fertility awareness-based methods.
    • Hearing Screening:
      • Added CPT codes 92550, 92567, 92579, and 92582.
      • Added hearing screening for adolescents age 11 years through 21 years (effective February 1, 2018 as plans renew).
    • Removed ICD-9-CM diagnosis codes.
    • Updated vaccine CPT code descriptions.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective February 15, 2018:
Cerliponase Alfa – (1807) New
  • Supports medical precertification.
Denosumab - (1212) Modified
  • Important changes in coverage criteria:
    • Expanded Xgeva criteria to include new FDA-approved indication for prevention of skeletal-related events in patients with multiple myeloma.
    • Removed criteria that are labeled contraindications:
      • Individual is not pregnant and no pre-existing hypocalcemia.
Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List - (1601) Modified
  • Important changes in coverage criteria:
    • Updated criteria for Invokana and Invokamet/Invokamet XR to include all covered alternatives.
    • Added criteria for ArmonAirTM, Imitrex, Syndros, and Ziana®.
    • Added Qvar® RediHaler as an alternative for inhaled corticosteroids.
    • Removed criteria for Glyxambi:
      • Added as preferred brand effective January 1, 2018.
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 criteria for Invokana and Invokamet/Invokamet XR to include all covered alternatives.
    • Added criteria for ArmonAirTM, Imitrex, Syndros, and Ziana®.
    • Added Qvar® RediHaler as an alternative for inhaled corticosteroids.
    • Removed criteria for Glyxambi:
      • Added as preferred brand effective January 1, 2018.
Filgrastim – (1611) Modified
  • Important change in coverage criteria:
    • Modified criteria to allow continuation of Filgrastim therapy for the current cycle of chemotherapy instead of chemotherapy regimen based on communication from National Comprehensive Cancer Network (NCCN).
Implantable Hormone Pellets - (1504) Modified
  • Important changes in coverage criteria:
    • Expanded definition of low serum testosterone from below the laboratory’s normal reference range to include an option of specific values:
      • Aligns with criteria for topical and injectable testosterone therapy.
    • Updated EIU uses to include “treatment of menopausal symptoms” for Testopel.
Modafinil/Armodafinil - (1501) Modified
  • Important changes in coverage criteria:
    • Added Parkinson’s disease-related excessive daytime somnolence (EDS) as a covered indication, for Modafinil only:
      • Based on Level A recommendation by the American Academy of neurology.
    • Updated EIU uses statement to current standards.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Added Bosulif® (bosutinib) under specific criteria for initial therapy for chronic phase chronic myeloid leukemia (CML):
      • FDA approved and NCCN recommended.
    • Added specific criteria for Yescarta (axicabtagene ciloleucel):
      • Consistent with FDA-approved indication.
Pharmacy Prior Authorization - (1407) Modified
  • Important change in coverage criteria:
    • Added Syndros prior authorization criteria.
Quantity Limitations – (1201) Modified
  • Important change in coverage criteria:
    • Added quantity limitation of 42 capsules per 60 days for betrixaban (Bevyxxa).
Step Therapy – (1109) Modified
  • Important changes in coverage criteria:
    • Updated step therapy for non-steroidal anti-inflammatory drugs, proton pump Inhibitors, respiratory medications, and emerging drug therapy.
    • Clarified step 1 medications for global step therapy to include full generic ingredient name, formulation and as appropriate, strength, providing a reference brand name with trademark.
      • Removed in error with January 1, 2018 annual review.

Abatacept – (6112)

Anakinra – (4063)

Anti-Tumor Necrosis Factor Therapy - (9014)

Interleukin-12/23 and 17 Antagonists – (1017)

Natalizumab for Crohn’s Disease – (6017)

Tocilizumab – (1024)

Tofacitinib – (1410)

Vedolizumab – (1502)

Retired
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Two policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
Policies Status Details
Precertification Policies*
No updates for February 2018.
Policies Status Details
Reimbursement Policies*
No updates for February 2018.
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
No updates for February 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.