Policy Updates February 2020

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
Allergy Testing and Non-Pharmacologic Treatment - (0070)
  • Effective for dates of service beginning February 17, 2020, we will limit coverage for allergy testing in a 12-month rolling period for claims billed with the following Current Procedural Terminology (CPT®) codes:
    • 86003 - 80 units
    • 95004 - 80 units
    • 95024 - 40 units
  • The current medical coverage policy, Allergy Testing and Non-Pharmacologic Treatment (0070), will be updated to reflect this change.
  • Note: Only the line item for the CPT codes listed above will be affected.
Anesthesia Services for Interventional Pain Management Procedures in an Adult (0551)
  • Effective for dates of service beginning February 17, 2020, we will implement a new medical coverage policy, Anesthesia Services for Interventional Pain Management Procedures in an Adult (0551), to only allow sedation coverage for certain diagnoses specified in the policy, for interventional pain management services.
  • Note: This policy only applies to customers age 18 years and older.
Care Integration Services (R32)
  • We will implement a new reimbursement policy, Care Integration Services (R32), to deny codes for care integration as included in the reimbursement for the overall care of the customer.
  • The policy is effective for claims processed on or after February 17, 2020.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective February 15, 2020:
Allergy Testing and Non-Pharmacologic Treatment - (0070) Modified
  • Originally provided advance notification of important changes in coverage criteria on November 15, 2019, for changes effective February 15, 2020:
    • Added focused review of frequency for in vivo and in vitro allergy testing:
      • CPT code 86003: limit to 80 units.
      • CPT code 95004: limit to 80 units.
      • CPT code 95024: limit to 40 units.
Colorectal Cancer Screening and Surveillance – (0148) Modified
  • Important changes in coverage criteria:
    • Changed frequency criteria in existing policy statement for stool-based deoxyribonucleic acid (DNA) (i.e., Cologuard) testing from “three years” to “one to three years”.
    • Removed phrase “regarding the test frequency imposed by the manufacturer” from Cologuard testing policy statement.
Diabetes Equipment and Self-Management – (0106) Modified
  • Important change in coverage criteria:
    • Added coverage for Eversense implantable continuous glucose monitoring system.
Injectable Bulking Agents for Urinary Conditions and Fecal Incontinence – (0206) Modified
  • Important change in coverage criteria:
    • Removed requirement for 12 months conservative treatment for females with stress urinary incontinence.
      • Conservative treatment is required but no specified time frame.
Nucleic Acid Pathogen Panel – (0530) Modified
  • Important changes in coverage criteria:
    • Changed criteria for nucleic acid testing for candida including vaginal candidiasis:
      • Added additional indications as medically necessary.
Omnibus Codes - (0504) Modified
  • Important changes in coverage criteria:
    • Added thoracic electrical bioimpedance for measurement of cardiac output:
      • CPT code 93701.
      • Retiring Thoracic Electrical Bioimpedance for the Measurement of Cardiac Output - (0200).
    • Added donor-derived cell-free DNA (AlloSure®):
      • CPT code 81479.
Outpatient Acute Rehabilitation - (0441) Modified
  • Important changes in coverage criteria:
    • Updated to be silent on group therapy:
      • Moved group therapy codes from not covered to covered.
      • Aligns with recent changes to other coverage policies as group therapy is no longer excluded in plan language.
Percutaneous Revascularization of the Lower Extremities in Adults – (0537) Modified
  • Important changes in coverage criteria:
    • Updated policy statement for conservative medical therapy:
      • Added “attempted smoking cessation”.
      • Removed “dietary changes”.
    • Updated criteria for documentation of ankle brachial index and significant occlusive disease.
Plasmapheresis – (0153) Modified
  • Important changes in coverage criteria:
    • Multiple changes based on 2019 updates to the American Society for Apheresis (ASFA) Guidelines on the “Use of Therapeutic Apheresis in Clinical Practice”.
Prophylactic Oophorectomy or Salpingo-oophorectomy With or Without Hysterectomy – (0026) Retired
  • No longer has business value; therefore, will no longer be maintained.
Thoracic Electrical Bioimpedance for the Measurement of Cardiac Output – (0200) Retired
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • One Cigna-ASH CPG was updated with no change in coverage.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
  • No new guidelines for February 2020.
Policies Status Details
Administrative Policies
Preventive Care Services - (A004) Modified
  • Important changes:
    • Colorectal Cancer Screening: Stool-based deoxyribonucleic acid (DNA) (i.e., Cologuard):
      • Removed phrase “test frequency limitation imposed by the manufacturer.”
      • Changed criteria for frequency from “three years” to “one to three years”.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective February 1, 2020:
Fish Oil Triglycerides – (M0013) New
  • Supports medical precertification review requirements.
Cerliponase Alfa – (1807) Modified
  • Important changes in coverage criteria:
    • Added specialist requirement.
    • Added dry blood spots for deficiency of tripeptidyl peptidase 1 (TPP1) to current white blood cells or fibroblast criteria as clarification.
    • Added reauthorization criteria that individual must meet initial criteria.
    • Added to the experimental, investigational, or unproven (EIU) section any neuronal ceroid lipofuscinoses (NCLs) other than late infantile ceroid lipofuscinosis type 2 (CLN2).
Denosumab - (1212) Modified
  • Important changes in coverage criteria:
    • Modified bisphosphonate requirement criteria to align with Evenity (romosozumab) criteria in Pharmacy Prior Authorization – (1407).
    • Clarified number and formulations needed to fulfill failure/inadequate response bisphosphonate criterion.
    • Consolidated contraindication per FDA label, intolerance, inability to take, or not a candidate for, into one bullet to improve readability.
    • Aligned high fracture risk criteria to that of Evenity, Forteo, and Tymlos osteoporosis drug criteria.
Miltefosine – (P0019) Modified
  • Important changes in coverage criteria:
    • Removed age criterion limiting coverage for age 12 years and over.
    • Added coverage criteria for infections caused by the following free-living ameba infections:
      • Acanthamoeba species.
      • Balamuthia mandrillaris.
      • Naegleria fowleri.
    • Added authorization statement without change to current implementation intent.
Medication Administration Site of Care – (1605) Modified
  • Minor changes in coverage criteria/policy:
    • Added Reblozyl (luspatercept-aamt).
    • Added Xembify (immune globulin subcutaneous, human-klhw).
Multiple Sclerosis Therapy - (1402) Modified
  • Important changes in coverage criteria:
    • Expanded coverage for the following to include active secondary progressive multiple sclerosis, responsive to FDA label updates:
      • Aubagio.
      • Copaxone.
      • Gilenya.
      • Glatiramer acetate (by Mylan).
      • Glatopa (glatiramer acetate, by Sandoz).
      • Ocrevus.
      • Plegridy.
      • Tecfidera.
      • Tysabri.
    • Expanded coverage for the following to include clinically isolated syndrome responsive to FDA label updates:
      • Aubagio.
      • Gilenya.
      • Ocrevus.
      • Plegridy.
      • Tecfidera.
      • Tysabri.
    • Updated each Copaxone criteria statement to clarify intent.
    • Updated each “Active Secondary Progressive Multiple Sclerosis” and “Clinically Isolated Syndrome” statement (calling out monotherapy), to clarify criteria intent.
Oncology Medications - (1403) Modified
  • Minor change in coverage criteria/policy:
    • Added Brukinsa (zanubrutinib) to pharmacy benefit table.
    • Added Padcev (enfortumab vedotin-ejfv) to medical precertification table.
    • Added Enhertu® (fam-trastuzumab deruxtecan-nxki) to medical precertification table.
Pharmacy Prior Authorization – (1407) Modified
  • Important changes in coverage criteria:
    • Added new criteria addressing pharmacy prior authorization or medical precertification of Evenity (romosozumab).
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for February 2020
Policies Status Details
Precertification Policies*
  • No updates for February 2020.
Policies Status Details
Reimbursement Policies*
Genetic Testing Panels – (R28) Modified
  • Advance notification of important changes, effective April 4, 2020:
    • Updated to note tumor profiling panels (CPT 81445, 81450, 81455) and hereditary cancer panels (CPT 81432, 81433, 81435, 81436) are subject to unbundling edits.
      • If multiple panel specific units are identified on a claim(s) from the same provider on the same date of service, the individual genetic testing codes will be rebundled and reimbursement will be made based on the panel code(s), which are similar to and more accurately reflect the service provided.
Policies Status Details
ClaimsXten*
  • No updates for February 2020.

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.