Policy Update January 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective January 15, 2017:
Capsule Endoscopy – (0008) New
  • Original coverage policy was retired in February 2013.
  • Being reactivated with new information, effective January 15, 2017.
  • Important changes in coverage criteria:
    • Changed from not covered to covered for surveillance of the small bowel in specific populations:
      • e.g. people with an inherited polyposis syndrome who have no known contraindications.
Omnibus Codes - (0504) Modified
  • Important changes in coverage criteria:
    • Removed CPT codes specific to capsule endoscopy.
    • Added the specific codes to Capsule Endoscopy – (0008)
Transcatheter Closure of Septal Defects - (0011) Modified
  • Important changes in coverage criteria:
    • Added coverage for transcatheter closure of a known patent foramen ovale (PFO).
Ventricular Assist Devices (VADs) and Percutaneous Cardiac Support Systems – (0054) Modified
  • Important changes in coverage criteria:
    • Added policy statement about permanently implantable counterpulsation VADs.
      • Currently no FDA-approved permanently implantable devices.
      • New 2017 HCPCS codes are specific to permanently implantable aortic counterpulsation VADs.
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Effective January 1, 2017, new preferred products were updated in all of the following policies:
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:
    • Added several products consistent with the general criteria approach outlined below:
      • Drugs or biologics with a significantly higher cost compared to their therapeutic alternatives (where all other clinical factors are the same): a maximum of five therapeutic alternatives required.
      • Non-preferred products: alternatives limited to the preferred product(s).
      • Multisource brand drugs: alternatives include generic equivalents, as well as therapeutic alternatives.
      • Single-source combination products: alternatives include the individual components taken separately.
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:
    • Added several products consistent with the general criteria approach outlined below:
      • Drugs or biologics with a significantly higher cost compared to their therapeutic alternatives (where all other clinical factors are the same): a maximum of five therapeutic alternatives required.
      • Non-preferred products: alternatives limited to the preferred product(s).
      • Multisource brand drugs: alternatives include generic equivalents, as well as therapeutic alternatives.
      • Single-source combination products: alternatives include the individual components taken separately.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Updated medical necessary criteria for Gleevec® to require documented intolerance to generic imatinib tablets.
    • Added Lartruvo® (olaratumab) to support medical precertification.
Pharmacy Prior Authorization – (1407) Modified
  • Important changes in coverage criteria:
    • Added the following to be consistent with FDA-approved indication and AHFS off-label indications:
      • Evzio® (naloxone)
      • Addyi (flibanserin).
Pulmonary Hypertension (PH) Therapy – (6121) Modified
  • Important changes in coverage criteria:
    • Updated medical necessary criteria for Revatio:
      • Will require documented intolerance to generic sildenafil.
Somatropin (Genotropin®, Humatrope®, Norditropin FlexPro®, Nutropin®, Nutropin® AQ, Omnitrope®, Saizen®, Serostim®, Zomacton, Zorbtive®) – (4012) Modified
  • Important changes in coverage criteria:
    • Updated preferred products:
      • Employer Group Benefit Plans: Preferred product will be Humatrope exclusively.
      • Individual and Family Benefit Plans: Preferred products will continue to be Humatrope and Saizen.
      • Serostim and Zorbtive will continue to be preferred products for their unique indications.
    • Updated experimental, investigational, or unproven (EIU) list to include:
      • Celiac disease
      • Glucocorticoid-induced growth failure.
    • Added clarifying statement that the presence of a comorbid condition found on the EIU list does not exclude an individual from therapy if criteria is otherwise met.
    • Added separate not covered statement for growth hormone in combination in GnRH for clarity.
Step Therapy – (1109) Modified
  • Important changes in coverage criteria:
    • Added or removed several medications with significant changes happening in the following areas:
      • New oral narcotic step therapy class.
      • Increase in the number of required generic prerequisites from one to two in the following classes:
        • nasal steroids
        • statins.
      • Clearly defined clinical exemption to the step therapy requirements as being an individual who is stabilized on therapy where therapeutic interchange is not appropriate in several classes.
Step Therapy Individual and Family Plan – (1603) Modified
  • Important changes in coverage criteria:
    • Added or removed several medications with significant changes happening in the following areas:
      • New oral narcotic step therapy class.
      • New long-acting insulin class.
      • Clearly defined clinical exemption to the step therapy requirements as being an individual who is stabilized on therapy where therapeutic interchange is not appropriate in several classes.
Effective January 15, 2017, the following policies were modified:
Dimercaprol (BAL in Oil®) and Edetate Calcium Disodium (Calcium Disodium Versenate®) - (6019) Modified
  • Important changes in coverage criteria:
    • Changed title from “Chelation Therapy” to current title.
    • Added lead blood levels to criteria requirement for both dimercaprol and edetate calcium disodium.
    • Added treatment of mercury toxicity from dental amalgam fillings as EIU.
    • Added HCPCS code, J3520 “edetate disodium” as EIU.
    • Added statement that edetate disodium is not an FDA-approved agent.
Lomitapide Mesylate (Juxtapid®) , Mipomersen Sodium (Kynamro®) - (1507) Modified
  • Important changes in coverage criteria:
    • Added minimum three month trial for inadequate response with Repatha criteria.
    • Added inability to use Repatha to Juxtapid criteria due to differences in administration:
      • Repatha is subcutaneous and Juxtapid is oral.
    • Removed prescriber specialist requirement.
Tesamorelin (Egrifta®) - (1112) Modified
  • Important changes in coverage criteria:
    • Removed requirement of CT scan demonstrating an increase in visceral adipose tissue.
    • Decreased authorization approval duration from 12 to 6 months.
Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use - (1206) Modified
  • Important changes in coverage criteria:
    • Added statement that use of more than one VEGF inhibitor in the same eye is considered EIU.
    • Clarified that coverage of Lucentis® for diabetic retinopathy with diabetic macular edema includes:
      • Non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR) based on FDA-labeled indication.
Policies Status Details
Administrative Policies
Unless otherwise noted, the following coverage policies were modified effective Januray 15, 2017:
A004 Preventive Care Services Modified
  • Important changes:
    • Added screening and behavioral interventions for abnormal blood glucose and type 2 diabetes.
    • Added screening for high blood pressure outside the clinical setting.
    • Added Kyleena® intrauterine device.
    • Updated coding sections for screening for:
      • abdominal aortic aneurysm
      • anemia
      • breast cancer
      • Hepatitis B
      • fall prevention
      • health risk assessment
      • smoking and tobacco cessation
      • routine immunizations
    • Removed reference to retired “Guide to Cigna's Preventive Health Coverage for Health Care Professionals” from the Related Coverage Resources section.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Thirteen policies have been posted to the CareAllies Medical Necessity Guidelines(CAMNG).
*Please log in to view these policies.
Policies Status Details
Precertification Policies*
Master Outpatient Precertification List Modified
  • Important changes effective January 1, 2017:
    • Added 54 CPT and 30 HCPCS codes:
      • New codes released by American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS)
Policies Status Details
Reimbursement Policies*
R16 Dialysis Services and Supplies Modified
  • Important changes:
    • Updated policy template.
    • Removed diagnosis code tables.
    • Added vitamins to list of drugs not separately reimbursed.
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
Code Edit and Policy Guidelines Modified
  • Important changes effective February 18, 2017:
    • ClaimsXten will be updated to First Quarter Knowledge Base content and NCCI Version 23.0 for all medical and behavioral claims.
Policies Status Details
Policies with a Reduction in Coverage
There were no additional policy updates for January 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.