Policy Updates January 2019

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
We are changing how we reimburse for the following policy:
Cardiac Electrophysiological (EP) Studies – (0532)
  • We have implemented a new medical coverage policy to support precertification for cardiac electrophysiological (EP) studies. The new medical coverage policy is Cardiac Electrophysiological (EP) studies (0532).
  • Precertification will be required for cardiac EP studies billed with Current Procedural Terminology (CPT®) codes 93619, 93620, 93621, 93622, 93623, 93624, 93654, 93655, and 93662.
  • The policy is effective for dates of service beginning January 1, 2019.
Policies Status Details
Medical Coverage Policy
Cardiac Electrophysiological (EP) Studies – (0532) New
  • Advance notification of new policy originally provided on October 1, 2018; policy effective January 1, 2019.
Percutaneous Revascularization of the Lower Extremities in Adults – (0537) New
  • Advance notification of policy effective April 1, 2019.
Prosthetic Devices – (0536) New
  • Combines policy statements from three policies; one active:
    • Myoelectric Devices: Upper Limb – (0233)
  • Two being retired:
    • Prosthetic Devices: Lower Limb (Including Vacuum-Assisted Socket System and Microprocessor/Computer-Controlled Lower Limb Prostheses) – (0194)
    • Prosthetic Devices: External Facial, Internal Ocular – (0331)

Stem Cell Transplantation: Solid Tumors – (0534)

New
  • Replaces five policies being retired:
    • Stem-Cell Transplantation for Neuroblastoma – (0189)
    • Stem-Cell Transplantation for Solid Tumors in Children – (0385)
    • Stem-Cell Transplantation for Adult Solid Tumors – (0479)
    • Stem-Cell Transplantation for Breast Cancer – (0100)
    • Stem-Cell Transplantation for Central Nervous System Tumors – (0369)
      • No changes to current coverage.
Hospital Beds and Accessories - (0273) Modified
  • Important changes in coverage criteria:
    • Updated to cover total electric beds.
Intervertebral Disc (IVD) Prosthesis - (0104) Modified
  • Important changes in coverage criteria:
    • Added policy statements for revision of a lumbar or cervical intervertebral disc prosthesis.
Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, Including Sacroiliac Fusion - (0303) Modified
  • Important changes in coverage criteria:
    • Added hybrid dynamic stabilization systems to existing policy statement.
Omnibus Codes - (0504) Modified
  • Important changes:
    • Added new codes in ophthalmology section (0506T, 0507T).
      • No change in coverage criteria.
Stem Cell Transplantation: Blood Cancers – (0533) Modified
  • Important changes in coverage criteria:
    • Clarified criteria to 3 of the 13 cancer types.
Vitamin D Testing - (0526) Modified
  • Important change:
    • Updated policy statement.
      • No change in coverage criteria.
Five policies retired and replaced with Stem Cell Transplantation: Solid Tumors – (0534) Retired
  • Stem-Cell Transplantation for Adult Solid Tumors – (0479)
  • Stem-Cell Transplantation for Breast Cancer – (0100)
  • Stem-Cell Transplantation for Central Nervous System Tumors – (0369)
  • Stem-Cell Transplantation for Neuroblastoma – (0189)
  • Stem-Cell Transplantation for Solid Tumors in Children – (0385)
Two policies retired and replaced with Prosthetic Devices – (0536) Retired
  • Prosthetic Devices: External Facial, Internal Ocular – (0331)
  • Prosthetic Devices: Lower Limb (Including Vacuum-Assisted Socket System and Microprocessor/Computer-Controlled Lower Limb Prostheses) – (0194)
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
No updates for January 2019.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Modified
Policies Status Details
Administrative Policies
Preventive Care Services - (A004) Modified
  • Important changes, effective January 1, 2019:
    • Alcohol Misuse/Substance Abuse Screening and Counseling:
      • Added code G2011.
    • BRCA1/BRCA2 Genetic Testing:
      • Added codes 81163, 81164, 81165, 81166, 81167.
      • Deleted codes 81211, 81213, 81214.
    • Cervical Cancer Screening:
      • Updated HPV/DNA test to alone or in combination with Pap smear.
    • Hearing Screening:
      • Added to Code Group 1: Z01.10, Z01.110, and Z01.118.
    • Updated coding table:
      • Removed deleted codes.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Elagolix - (P0065) New
  • Effective January 15, 2019.
  • Supports prior authorization and quantity limits.
Hydroxyurea Tablet – (P0052) New
  • Effective February 1, 2019.
  • Supports prior authorization on new hydroxyurea formulation, Siklos tablet.
Enzyme Related Therapies - (1319) Modified
  • Important changes in coverage criteria, effective February 1, 2019:
    • Added new criteria for Revcovi:
      • New FDA-approved product for adenosine deaminase (ADA) deficiency.
    • Updated Adagen criteria to mirror Revcovi to include failed bone marrow/stem cell transplantation (BMT/SCT) or unable to have HLA-identical related donor transplant.
    • Updated Sucraid criteria to eliminate hydrogen breath test; strengthen biopsy assay criteria and add genetic testing criteria option.
    • Added a six-month initial authorization period and reauthorization:
      • Requires evidence of beneficial clinical response.
Hepatitis C Therapy - (1316) Modified
  • Important changes in coverage criteria, effective January 1, 2019:
    • Added language noting that authorized generics are preferred products for Employer Group and brand products remain preferred products for Individual and Family Plans.
Ivabradine – (P0010) Modified
  • Important changes in coverage criteria:
    • Expanded coverage for the off-label use in the treatment of inappropriate sinus tachycardia.
    • Added postural orthostatic tachycardia syndrome and stable angina as experimental, investigational, or unproven (EIU) conditions.
Oncology Medications – (1403) Modified
  • Important changes in coverage criteria:
    • Added Vitrakvi, Daurismo, and Xospata to pharmacy benefit table.
    • Added Khapzory to medical benefit table.
Testosterone Therapy - (1503) Modified
  • Important changes in coverage criteria:
    • Revised and clarified laboratory values based on clinical guideline update.
    • Added statement that authorization will be limited to the maximum FDA recommended dosing.
Two policies retired on January 1, 2019. Retired
  • Apremilast - (1414)
  • Controlled Substance Analgesic and Narcotic Antagonist Quantity Limitations – (1706)
    • Incorporated controlled substance quantity limitations into Opioid Therapy – (1704).
    • Moved the following products not included in the Opioid Therapy policy to Quantity Limitations – (1201):
      • Butalbital-caffeine-aspirin (Fiorinal) capsule
      • Buprenorphine (Butrans) patch
      • Buprenorphine (Belbuca) buccal film
      • Butorphanol nasal spray
      • Naloxone (Evzio) injection
      • Naloxone (Narcan) nasal spray
      • Naltrexone tablet
      • Tramadol (Ultram) tablet
      • Tramadol ER (Conzip) capsule
      • Tramadol ER tablet
      • Tramadol HCL ER 150mg capsule
      • Tramadol/Acetaminophen (Ultracet) tablet
Policies Status Details
CareAllies Medical Necessity Guidelines
No updates for January 2019.
Policies Status Details
Precertification Policies*
Updated Master Precertification List
Policies Status Details
Reimbursement Policies*
No updates for January 2019.
Policies Status Details
ClaimsXten*
Code Edit and Policy Guidelines
  • Important changes, effective February 16, 2019:
    • ClaimsXten will be updated to the First Quarter Knowledge Base content and NCCI Version 25.0 for all medical and behavioral claims.

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.