Policy Updates February 2022

Note – Log-in is required for policy update sections marked with an asterisk *. Use this link to log-in, Cigna for Health Care Professionals > Resources > Reimbursement and Payment Policies

Policies Update to Coverage
Policies With a Reduction in Coverage
  • No updates for February 2022.
Policies Status Details
Medical Coverage Policies
  • Unless otherwise noted, the following medical coverage policies were modified effective February 15, 2022:
Vascularized Composite Allograft (VCA) Transplantation – (0560) New
  • Supports vascularized composite allograft (VCA) transplantation.
    • Nonspecific codes already require precertification.
Anesthesia for Interventional Pain Management In the Adult – (0551) Modified
  • Important changes in coverage criteria:
    • Added clarifications about monitored anesthesia care (MAC).
Autonomic Nerve Function Testing – (0506) Modified
  • Important changes in coverage criteria:
    • Added clarification, including examples, to existing policy statement addressing autonomic nerve function testing using a portable, automated device.
Bone, Cartilage, and Ligament Graft Substitutes – (0118) Modified
  • Important changes in coverage criteria:
    • Added clarification to existing criteria for bone marrow aspirate that is processed/centrifuged.
Drug Testing – (0513) Modified
  • Minor changes in coverage criteria/policy:
    • Added new policy statement addressing HCPCS codes G0481, G0482, and G0483.
High Intensity Focused Ultrasound (HIFU) – (0274) Modified
  • Important changes in coverage criteria:
    • Updated existing policy statement and criteria about recurrent prostate cancer to align with the National Comprehensive Cancer Network® (NCCN).
Hospice Care – (0462) Modified
  • Important changes in coverage criteria:
    • Updated criteria based on updated benefit plan language:
      • Increased duration of eligibility for hospice.
      • Updated to allow concurrent care between hospice and curative care treatment.
Molecular Diagnostic Testing for Hematology/Oncology Indications – (0520) Modified
  • Important changes in coverage criteria:
    • Expanded criteria for broad molecular profiling panels to include testing for:
      • All advanced, metastatic solid tumors.
      • Hematologic malignancies as follows:
        • Acute myeloid leukemia.
        • Myelodysplastic disease.
        • Myeloproliferative disease.
        • Multiple myeloma.
        • Systemic mastocytosis.
    • Updated liquid biopsy criteria to include advanced, metastatic solid tumors.
    • Updated criteria and policy statement for minimal residual disease testing to delineate high-throughput testing (e.g., ClonoSEQ) and non-high-throughput methods of immunosequencing.
    • Added peripheral and cutaneous T-cell lymphoma as indication for high-throughput testing.
    • Removed acute myeloid leukemia:
      • Not recommended by NCCN.
    • Added several new tests to “Screening and Prognostic Tests for Early Detection of Prostate Cancer” section and revised criteria.
    • Revised criteria for several tests in “Tumor Tissue-Based Molecular Assays for Detection of Prostate Cancer” section and updated definitions.
    • Updated criteria for polycythemia vera, essential thrombocythemia and primary myelofibrosis.
    • Removed criteria on testing for solid tumor cancers:
      • Included in criteria for biomarker and broad molecular profile testing.
Percutaneous Revascularization of the Lower Extremities in Adults – (0537) Modified
  • Important change in coverage criteria:
    • Added monophasic waveform by ultrasound for clarification.
Speech Therapy – (0177) Modified
  • Important changes in coverage criteria:
    • Updated criteria for therapy to prevent recurrence to align with benefit plan language.
    • Updated educational programs criteria to address intensive speech programs that focus on learning disabilities.
Inpatient Acute Rehabilitation – (0427) Retired
  • No longer has business value; therefore, will no longer be maintained.
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • No updates for February 2022.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Gastrointestinal Endoscopic Procedures Guidelines Modified
  • Originally provided advance notification on December 15, 2021, of important changes to capsule endoscopy section, effective March 1, 2022:
    • Added new indication for evaluation of the following when criteria is met:
      • Familial Adenomatous Polyposis (FAP).
      • Attenuated Familial Adenomatous Polyposis (AFAP) Syndromes.
      • MUTYH-Associated Polyposis.
    • Other editorial and formatting changes to improve clarity.
    • Updated section with general information related to guidelines and medical necessity review.
Radiation Oncology Guidelines Modified
  • Advance notification of important changes, effective May 1, 2022:
    • Updated existing policy statement and criteria on selective internal radiation therapy (SIRT) using radioactive Yttrium-90 microspheres.
Sleep Disorders Diagnosis and Treatment Guidelines Modified
  • Minor changes, originally communicated on December 15, 2021, effective March 1, 2022:
    • Updated definitions and other editorial changes.
Policies Status Details
Administrative Policies
  • No updates for February 2022.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective February 1, 2022:
Fenofibrates – (IP0339) New
Palivizumab - (IP0321) New
  • Replaces Palivizumab – (5012)
  • Supports medical precertification.
  • Modified criteria for “Respiratory Syncytial Virus (RSV), Prevention in an Individual with Congenital Heart Disease”:
    • Added coverage for individuals who continue to require medication for congestive heart failure following cardiac surgery.
    • Updated specialist requirement to include neonatologist or pulmonologist.
  • Added specialist prescribing requirement for “Respiratory Syncytial Virus (RSV), Prevention in individuals with Cardiac Transplant, Cystic Fibrosis and Immunocompromised Individuals”.
Pegvisomant - (IP0291) New
  • Supports pharmacy prior authorization.
  • Moved content from Pharmacy Prior Authorization - (1407).
  • Added requirement for confirmed acromegaly diagnosis by either an elevated insulin-like growth factor-1 (IGF-1) level, or by growth hormone (GH) suppression testing.
  • Added specialist prescribing requirement.
Abaloparatide - (IP0329) and Teriparatide – (IP0330)
  • Replace Parathyroid Hormone Analogs (Osteoporosis) – (P0025).

Darbepoetin alfa (Aranesp) – (IP0293) and Epoetin Alpha Products – (IP0296) and Methoxy polyethylene glycol-epoetin beta (Mircera) – (IP0297)
  • Support both pharmacy prior authorization and medical precertification, where applicable.
  • Replace Erythropoiesis Stimulating Agents – (5016)

Hereditary Angioedema – C1 Esterase Inhibitors (Subcutaneous) – (IP0316)
  • Supports prior authorization for Haegarda.
  • Replaces Hereditary Angioedema Therapy – (1019).

Hereditary Angioedema – Ecallantide – (IP0336)
  • Supports prior authorization for Kalbitor.
  • Replaces Hereditary Angioedema Therapy – (1019).

Hereditary Angioedema – Icatibant – (IP0335)
  • Supports prior authorization for Firazyr and Sajazir.
  • Replaces Hereditary Angioedema Therapy – (1019).

Hereditary Angioedema – Lanadelumab-flyo – (IP0334)
  • Supports prior authorization for Takhzyro.
  • Replaces Hereditary Angioedema Therapy – (1019).

Midazolam Nasal Spray – (IP0338)
  • Replaces Midazolam Nasal Spray – (P0108).

Pyrimethamine – (IP0348)
  • Effective February 15, 2022.
  • Replaces Pyrimethamine – (P0012)

Topical Ruxolitinib - (IP0369)
  • Effective February 15, 2022.

Upadacitinib - (IP0229)

Vedolizumab – (IP0326)
  • Replaces Vedolizumab – (M0005)

New
  • Supports pharmacy prior authorization requirements.
Denosumab (Prolia) – (IP0331) and Denosumab (Xgeva) – (IP0332)
  • Replaces Denosumab – (1212).

Human Chorionic Gonadotropin (hCG) for Non-fertility Uses - (IP0327)
  • Replaces Human Chorionic Gonadotropin (hCG) for Non-fertility - (1815)
  • Supports medical precertification for human chorionic gonadotropin (chorionic gonadotropin, Novarel®, Pregnyl®).
  • Includes criteria for diagnostic testosterone stimulation test.
  • Clarified conditions not covered due to hypogonadotropic hypogonadism.

Lanreotide for Non-Oncology Uses - (IP0323)
  • Replaces Lanreotide for Non-Oncology Uses - (9005)
  • Revised criteria for acromegaly.

Purified Cortrophin Gel – (IP0374)
New
  • Supports medical precertification requirements.
Gabapentin Extended-Release – (IP0317)
  • Replaces Gabapentin – (P0043).

Gonadotropin-Releasing Hormone (GnRH) Antagonists for Infertility Use – (IP0333)
Pulmonary Long-Acting Beta2-Agonist Inhalers – (IP0359)
New
  • Supports medical necessity review criteria requirements.
Lybalvi – (IP0368)
  • Effective February 15, 2022.

Otic Antibiotics – (IP0366)

Thalitone – (IP0365)

Topical Medications for Actinic Keratosis – (IP0367)
  • Effective February 15, 2022.
  • For Aldara, Carac, imiquimod 3.75% (A-rated and authorized generics for Zyclara), Klisyri, and Zyclara.
New
  • Supports medical necessity exception criteria.
COVID-19 Drug and Biologic Therapeutics - (2016) Modified
  • Important changes in coverage criteria, effective January 27, 2022:
    • Modified remdesivir (Veklury) criteria consistent with most recent Emergency Use Authorization (EUA) issued January 21, 2022 and FDA label update that expanded for use in the outpatient setting.
    • Modified bamlanivimab-etesevimab and REGEN-COV criteria consistent with most recent EUA and Health Care Provider Fact Sheet issued on January 21, 2022 that prohibits use of these products in geographic regions where infection is likely to have been caused by a non-susceptible SARS-CoV-2 variant.
Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List – (1601) Modified
Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List – (1602) Modified
Glucagon Products – (IP0039) Modified
  • Minor change in coverage criteria/policy:
    • Added kit formulation of Gvoke product.
Grazoprevir/Elbasvir – (IP0158) Modified
  • Important change in coverage criteria, effective February 15, 2022:
    • Revised due to FDA labeling update.
Infertility Medications – (1012) Modified
Insulin Glargine – (P0023) Modified
  • Minor change in coverage criteria:
    • Added Semglee authorized generic.
Interferon Therapy - (1315) Modified
Medication Administration Site of Care - (1605) Modified
  • Minor changes in coverage criteria/policy, effective February 1, 2022:
    • Updated coding for:
      • Aduhelm.
      • Jemperli.
      • Neulasta.
      • Nexviazyme.
      • Saphnelo.
  • Minor changes in coverage criteria/policy, effective February 15, 2022:
    • Added the following agents to Medication Administration Site of Care point of authorization:
      • Leqvio.
      • Nulojix.
      • Vyvgart.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria, effective February 1, 2022:
    • Added notation that Farydak was withdrawn from market in December 2021.
    • Added to pharmacy and/or medical table:
      • Besremi.
      • Exkivity.
      • Fyarro.
      • Scemblix.
  • Important changes in coverage criteria, effective February 15, 2022:
    • Added criteria for Scemblix for chronic myeloid leukemia, Philadelphia chromosome positive.
Opioid therapy - (1704) Modified
  • Minor changes in coverage criteria/policy:
    • Updated extended-release opioid analgesic products preferred product list.
Oxybate - (IP0103) Modified
  • Important changes in coverage criteria:
    • Added dextroamphetamine as guideline recommended prerequisite option for Cataplexy.
    • Removed amphetamine as prerequisite option and added dextroamphetamine as prerequisite option for excessive daytime sleepiness associated with narcolepsy.
    • Added criteria for Idiopathic Hypersomnia, Xywav only.
    • Added concomitant use of Xyrem and Xywav as excluded use in conditions not covered section.
Oxymetazoline Ophthalmic Solution - (IP0088) Modified
  • Important changes in coverage criteria:
    • Added clarifying language to conditions not covered - blepharoptosis.
      • No change to criteria intent.
Pharmacy Prior Authorization - (1407) Modified
  • Important changes in coverage criteria:
Pitolisant - (IP0292) Modified
  • Important change in coverage criteria:
    • Revised criteria for cataplexy associated with narcolepsy to add dextroamphetamine to list of alternatives.
Proton Pump Inhibitors – (IP0061) Modified
  • Important change in coverage criteria, effective Febraury 15, 2022 :
    • Added Dexilant authorized generic.
Romosozumab – (IP0179) Modified
  • Important changes in coverage criteria:
    • Added criteria for individuals at very high risk of fracture.
    • Relocated criteria for concomitant use of other osteoporosis medications to conditions not covered section.
    • Updated reauthorization and authorization duration sections.
Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) – (1803) Modified
  • Minor changes in coverage criteria/policy, effective February 15, 2022:
    • Added Lybalvi to the “Step 3 Medications” for atypical antipsychotic agents.
Voxelotor – (IP0119) Modified
  • Important change in coverage criteria, effective February 15, 2022:
    • Revised due to FDA labeling update for age down to four years of age.
Denosumab – (1212) Retired
Erythropoiesis Stimulating Agents – (5016) Retired
Gabapentin – (P0043) Retired
Hereditary Angioedema Therapy – (1019) Retired
Human Chorionic Gonadotropin (hCG) for Non-fertility - (1815) Retired
Lanreotide for Non-Oncology Uses - (9005) Retired
Midazolam Nasal Spray – (P0108) Retired
Palivizumab - (5012) Retired
Parathyroid Hormone Analogs (Osteoporosis) – (P0025) Retired
Pyrimethamine – (P0012) Retired
Vedolizumab – (M0005) Retired
Policies Status Details
Cigna National Formaulary (CNF) Coverage Policies
  • Cigna National Formulary (CNF) policies are located on the CNF Policies A-Z Index.
    • Policies are listed alphabetically by document title
      • Document titles include the policy type and may include the drug name, class, and/or condition
    • Policies can also be searched by a product identification (ID) number, which is a unique identifier to a specific product/policy.
      • When applicable, searching by product ID helps locate the corresponding CNF policy.
    • Details of updates to each CNF policy are located under the “Revision History” section.
  • More information about Cigna's drug lists can be found at Prescription Drug Lists and Coverage | Cigna
  • More information about Cigna's drug lists changes can be found at CHCP - Resources - Cigna's Prescription Drug Lists.
    • CNF formulary changes can be found in the Prescription Drug List Changes document under Cigna National Prescription Drug List, located at the bottom of the page.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for February 2022
Policies Status Details
Precertification List – Commercial (Non-Medicare) Business*
Precertification Changes – April 2022 Modified
  • Important changes, effective April 1, 2022:
    • Adding 14 new PLA codes to precertification/MNR.
Policies Status Details
Precertification List – Medicare Business
  • No updates for February 2022
Policies Status Details
Reimbursement Policies*
Advanced Practice Health Care Providers – (R37) New
  • Effective February 1, 2022.
Assistant Surgeon – Modifiers 80, 81, 82 Assistant-at-Surgery – Modifier AS Co-Surgeon (Two Surgeons) – Modifier 62 Surgical Team – Modifier 66 – (MAS)
Healthcare Common Procedure Coding System (HCPCS) National Level II Modifiers – (MHCPCS)
Omnibus Reimbursement Policy – (R24)
Modified
  • Updated policies.
Policies Status Details
ClaimsXten*
  • No updates for February 2022

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.