Policy Updates January 2018

Important New Information
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective January 15, 2018:
Breast Reconstruction Following Mastectomy or Lumpectomy – (0178) Modified
  • Important changes in coverage criteria:
    • Added three products to existing not covered policy statement:
      • Cortiva
      • Juvederm®
      • Phasix Mesh

Genetic Testing for Heritable and Multifactorial Conditions – (0052)

Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias – (0517)

Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis – (0514)

Tumor Profiling, Gene Expression Assays and Molecular Diagnostic Testing for Hematology/Oncology Indications – (0520)

Modified
  • Important change in coverage criteriafor all of the policies listed:
    • Added coverage of multigene panel genetic testing if medical necessity criteria for at least one gene are met and panel test is contracted with Cigna.
Genetic Testing for Hereditary Cancer Susceptibility Syndromes – (0518) Modified
  • Important changes in coverage criteria:
    • Added coverage of multigene panel genetic testing if medical necessity criteria for at least one gene are met and panel test is contracted with Cigna.
    • Added coverage of genetic testing without pretest genetic counseling in certain breast cancer scenarios.
High Intensity Focused Ultrasound (HIFU) – (0274) Modified
  • Important changes in coverage criteria:
    • Added new covered policy statements for recurrent prostate cancer and bone cancer pain palliation.
Home Blood Glucose Monitors – (0106) Modified
  • Important change in coverage criteria:
    • Added new covered policy statement for the Freestyle Libre continuous glucose monitor when criteria are met:
      • Not a change in coverage.
Hospital Beds and Accessories – (0273) Modified
  • Important change in coverage criteria:
    • Added coverage for a pediatric hospital bed with 360° enclosure in specific clinical scenarios.
Tissue-Engineered Skin Substitutes – (0068) Modified
  • Important changes in coverage criteria:
    • Added coverage for the following products when criteria are met:
      • AlloPatch® Pliable for diabetic foot ulcers.
      • AmnioBand® for diabetic foot ulcers
      • Suprathel® for burn wounds
    • Added 19 new products to existing not covered policy statement.
Policies Status Details
Cigna-ASH Coverage Policy Guidelines
No updates for January 2018.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Updated the Comprehensive Musculoskeletal Management (CMM) Guidelines for Implantable Intrathecal Drug Delivery System - (CMM 210).
  • Added criteria for opioid reduction before trial for noncancer pain.
Policies Status Details
Administrative Policies
Preventive Care Services – (A004) Modified
  • Updated screening services and coding table:
    • Abnormal blood glucose and type 2 diabetes screening:
      • Added CPT code 0488T.
    • Bilirubin screening:
      • Added CPT codes 82247 and 88720.
    • Breast cancer screening:
      • Removed deleted HCPCS codes G0202, G0204 and G0206.
    • Cervical cancer screening:
      • Added CPT code 0500T.
      • Removed deleted CPT code 88154.
    • Cholesterol screening for children/adolescents:
      • Updated age range to 17-21 years.
    • Colorectal cancer screening:
      • Added CPT code 00812
      • Removed deleted CPT code 00810
    • Female contraception counseling:
      • Added lactation amenorrhea method.
      • Intrauterine devices:
        • Added HCPCS code J7296.
        • Removed deleted HCPCS code Q9984.
    • Health-risk assessment/maternal depression screening:
      • Added CPT code 96161.
    • Office visits-prolonged services:
      • Added HCPCS codes G0513 and G0514.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective January 15, 2018:
Edaravone - (1806) New
  • Supports medical precertification.
Step Therapy - Standard Prescription Drug Lists (Employer Group Plans) - (1801) New
  • Supports the Utilization Management (UM) Rebuild Step Therapy program for Standard Prescription Drug Lists
Step Therapy - Value Prescription Drug Lists (Employer Group Plans) - (1802) New
  • Supports the Utilization Management (UM) Rebuild Step Therapy program for Value Prescription Drug Lists.
Step Therapy - Legacy Prescription Drug Lists (Employer Group Plans) - (1803) New
  • Supports the Utilization Management (UM) Rebuild Step Therapy program for Legacy Prescription Drug Lists.
Botulinum Therapy - (1106) Modified
  • Important changes in coverage criteria:
    • Added or rephrased criteria for upper limb or lower limb spasticity for all botulinum toxin serotype A products requiring documentation of decrease of function or activities of daily living.
    • Added criteria for upper and lower limb spasticity in adults for Myobloc®.
Oral Phosphodiesterase-5 (PDE5) Inhibitors - (7003) Modified
  • Important changes in coverage criteria:
    • Removed all oral PDE5 inhibitors from prior authorization (except Cialis 5mg) responsive to availability of generic sildenafil.
      • In place of prior authorization, an age edit has been added and step therapy will be added for non-preferred products.
      • Cialis 5mg remains on prior authorization as it is also indicated for benign prostatic hyperplasia (BPH).
    • Specified quantity limitations of 30 tablets per 30 days for the Cialis daily products and 8 tablets per 30 days for the remaining products.
    • Removed limited seven month duration authorization of Cialis for BPH when initiated with finasteride.
PCSK9 Inhibitors - (1509) Modified
  • Important changes in coverage criteria:
    • Expanded coverage to individuals with contraindication or intolerance to statin therapy.
    • Modified criteria for inadequate response to statin therapy or lipid lowering therapy regimens based on clinical practice guidelines.
    • Updated Praluent (alirocumab) dosing approval following updates to the FDA product information.
    • Extended approval duration from 3 months to 6 months for initial authorization and to 12 months for reauthorization.
    • Added that use in individuals with 2 null low-density lipoprotein receptor (LDLR) pathogenic variants and/or LDLR activity less than 2% is experimental, investigational, or unproven since therapy is not effective without a functional LDLR gene.
Somatropin - (4012) Modified
  • Important changes in coverage criteria:
    • Removed Saizen as a preferred product for Individual and Family Plans.
    • Added idiopathic insulin-like growth factor-1 ( IGF-1) deficiency:
      • Not medically necessary based on Pediatric Endocrine Society guidelines.
Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use - (1206) Modified
  • Important changes in coverage criteria:
    • Removed all bevacizumab (Avastin) criteria as it does not require precertification.
    • Added new FDA-approved indication for Lucentis:
      • Myopic choroidal neovascularization (mCNV).
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Two policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
*Please log in to view these policies.
Policies Status Details
Precertification Policies*
No updates for January 2018.
Policies Status Details
Reimbursement Policies*
No updates for January 2018.
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
Code Edit and Policy Guidelines Effective February 17, 2018, ClaimsXten will be updated to First Quarter Knowledge Base content and NCCI Version 24.0 for all medical and behavioral claims.
Policies Status Details
Policies with a Reduction in Coverage
There were no additional changes made in January 2018 that resulted in a reduction in 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.