Policy Updates January 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
Incontinence supplies
  • To ensure consistent claims processing, we will deny charges for all incontinence supplies when billed with Healthcare Common Procedure Coding System (HCPCS) codes that begin with “T” or “A” as not reimbursable. Incontinence supplies are used to meet daily needs and are not considered a covered medical benefit.
  • Note: No coverage or reimbursement policies are affected by this change.
  • This change is effective for claims processed on or after January 1, 2020.
  • Policies Status Details
    Medical Coverage Policies
    Unless otherwise noted, the following medical coverage policies were modified effective January 15, 2020:
    Biventricular Pacing/Cardiac Resynchronization Therapy (CRT) - (0174) Modified
    • Important change in coverage criteria:
      • Added new policy statement for His bundle pacing.
    Breast Implant Removal - (0048) Modified
    • Important changes in coverage criteria:
      • Removed criteria for persistent infection as a result of Baker Stage IV capsular contracture.
      • Added criteria for removal of Allergan Biocell textured breast implants and tissue expanders.
    Electroencephalography – (0521) Modified
    • Minor changes in coverage criteria/policy:
      • Updated existing policy statements for digital electroencephalography (EEG) spike analysis:
        • Removed the terms “ambulatory” and “video or quantitative EEG”.
    Intervertebral Disc (IVD) Prosthesis - (0104) Modified
    • Important change in coverage criteria:
      • Updated existing criteria for lumbar IVD prosthesis.
    Minimally Invasive Spine Surgery Procedures and Trigger Point Injections - (0139) Modified
    • Important changes in coverage criteria:
      • Updated codes for dry needling of trigger points.
      • Clarified policy statement for annular devices.
    Orthotic Devices and Shoes – (0543) Modified
    • Minor changes in coverage criteria/policy:
      • Clarified upper limb orthotic devices.
    Prosthetic Devices – (0536) Modified
    • Important changes in coverage criteria:
      • Added policy statements for:
        • Iris prosthesis.
        • Osseointegrated lower limb prosthesis.
        • Upper limb myoelectric prosthesis with sensors.
      • Removed weight criteria for power-assisted microprocessor lower limb prosthesis.
    Sacral Nerve and Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation – (0404) Modified
    • Important change in coverage criteria:
      • Added policy statement for implantable tibial nerve stimulation devices.
    Serological Testing for Inflammatory Bowel Disease - (0121) Modified
    • Advance notification of important changes in coverage criteria, effective April 15, 2020:
      • Expanded existing experimental, investigational, or unproven (EIU) policy statement noting serum drug level testing is EIU for the management of inflammatory bowel disease.
      • Updated existing policy statement to address class of drugs used to treat inflammatory bowel disease, rather than listing specific drugs:
        • Specific drugs used as examples only.
      • Updated test panel examples to list test name and remove drug name being tested.
    Policies Status Details
    American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
    • No new policies or updates for January 2020
    Policies Status Details
    Cigna-eviCore Cobranded Guidelines
    • The following Comprehensive Musculoskeletal Management (CMM) guidelines have been updated with minimal changes
      • Spinal Cord and Implanted Peripheral Nerve Stimulation – (CMM 211).
      • Sacroiliac Joint Injections – (CMM 203).
      • Implantable Intrathecal Drug Delivery Systems – (CMM 210).
      • Epidural Adhesiolysis – (CMM 207).
      • Prolotherapy – (CMM 204).
      • Facet Joint Injections/Medial Branch Blocks – (CMM 201).
      • Radiofrequency Joint Ablation/Denervation – (CMM 208).
    Policies Status Details
    Administrative Policies
    Preventive Care Services - (A004) Modified
    • Important changes, effective January 1, 2020:
      • Colorectal Cancer Screening:
        • Added CPT code 45333 when submitted with a wellness diagnosis code.
      • High Blood Pressure Screening Outside the Clinical Setting:
        • Added CPT codes 99473 and 99474 when submitted with diagnosis code R03.0.
      • Perinatal Depression Prevention-Interventions:
        • Added CPT codes 96156, 96158, 96159, 96164, 96165, 96167 and 96168 when submitted with a maternity diagnosis code.
      • Surgical Sterilization Procedure:
        • Added footnote indicating Essure device no longer available in U.S.
    Policies Status Details
    Pharmacy (Drugs & Biologics) Policies
    Unless otherwise noted, the following pharmacy coverage policies were modified effective January 1, 2020:
    Antimalarial Therapy – (P0101) New
    • Supports removal of benefit exclusion edit on antimalarial products used for treatment and prevention.
      • Expands access from a previously excluded class of therapy.
      • Now adding this access to all; however, prior authorization required to assure appropriate use.
    Barbiturates - (P0095) New
    • Supports prior authorization requirements with a step through all covered nonbarbiturate therapeutic alternatives, for all forms of Nembutal (pentobarbital) and Seconal (secobarbital).

    Cyanocobalamin Nasal Spray - (P0097)

    Inhaled Antibiotics Therapy – (P0102)

    Iron Chelating Agents – (P0090)

    Pregabalin – (P0078)

    Pyridostigmine – (P0107) (effective January 27, 2020)

    Solriamfetol – (P0106) (effective January 6, 2020)

    Tetracycline Antibiotics – (P0100)

    Topical Vitamin D Analogs - (P0077)

    New
    • Policies support prior authorization requirements
    Gabapentin - (P0043) New
    Parathyroid Hormone Analogs (Osteoporosis) – (P0025) New
    • Supports prior authorization for Forteo (teriparatide) and Tymlos (abaloparatide) across all employer group formularies.
    Weight Loss Medications – (P0104) New
    • Supports prior authorization for weight loss class when covered under specific plan design.
      • Prior authorization will not apply to any generics in the weight loss class.
    Abatacept Intravenous (Employer Group Benefit Plans) - (M0006) Modified
    Antifungals, Topical – (P0046) Modified
    • Important changes in coverage criteria:
      • Lowered minimum age requirement from 18 to 6 years of age and older:
        • Responsive to FDA label for pediatric use.
      • Aligned covered alternatives required before Luzu with covered alternatives currently required for Exelderm:
        • Use of these products are for like uses.
      • Aligned covered alternatives required before Oxistat cream and lotion with covered alternative currently required for Loprox cream:
        • These are the only products without criteria language screening for use; a total of five covered alternatives is required before Oxistat cream, Oxistat lotion, and Loprox cream.
    Attention Deficit Hyperactivity Disorder (ADHD) Stimulants - (P0047) Modified
    • Important changes in coverage criteria:
      • Updated criteria for each immediate-release product to note one of the diagnoses is required, as well as failure of up to four covered alternatives.
      • Updated criteria for each extended-release product to note one of the diagnoses is required, in addition to the current criteria found in the sections for the Standard/Performance and Value/Advantage formularies.
      • Added table containing all generic ADHD stimulant products:
        • Each product will be subject to diagnostic criteria found on right side of box.
      • Added Adhansia XR diagnostic criteria to the other stimulant products.
    Benralizumab, Mepolizumab and Reslizumab – (1608) Modified
    • Important changes in coverage criteria:
      • Modified mepolizumab (Nucala) medical necessity criteria to allow for expanded FDA labeling for asthma to include individuals ≥ six years of age.
      • Added newly FDA approved dosage forms and dosing recommendations for:
        • Fasenra pen (auto-injector).
        • Nucala (prefilled syringe and auto-injector).
      • Expanded EIU indications list to include:
        • Eosinophilic gastroenteritis.
        • Eosinophilic colitis.
        • Atopic dermatitis.
        • Chronic obstructive pulmonary disease (COPD).
    Complement Inhibitors – (1103) Modified
    • Important changes in coverage criteria:
      • Modified ravulizumab coverage criteria:
        • Responsive to FDA approval on October 18, 2019 for use of Ultomiris for treatment of atypical hemolytic uremic syndrome (aHUS) in individuals age one month and older.
      • Aligned ravulizumab coverage criteria with eculizumab coverage criteria for uses in treatment of aHUS and paroxysmal nocturnal hemoglobinuria (PNH).
      • Added eculizumab coverage criteria for neuromyelitis optica spectrum disorder (NMOSD):
        • Removed criterion requiring IVIg as a covered alternative because there is no support for using IVIg to treat NMOSD.
    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:
      • Removed Antiemetic products.
      • Removed Anti-infective agents – Tetracycline antibiotic products.
      • Removed Psychotherapeutic Drugs – Miscellaneous products.
      • Removed Qbrexza.
      • Removed Bethkis.
      • Removed Tobi.
        • Above products now in standalone coverage policies.
      • Added Spiriva Handihaler and Respimat (tiotropium).
      • Added Striverdi Respimat (olodaterol).
      • Added Stiolto Respimat (olodaterol-tiotropium).
      • Updated Seebri Neohaler (glycopyrrolate) criteria.
      • Updated Tudorza Pressair (aclidinium) criteria.
        • Above two updates made with removal of Spiriva as a covered alternative.
      • Updated Utibron Neohaler (indacaterol-glycopyrrolate) criteria.
      • Updated Bevespi Aerosphere (formoterol-glycopyrrolate) criteria.
        • Above two updates made with removal of Stiolto Respimat as a covered alternative.
      • Added ProAir Digihaler coverage criteria.
      • Added Duaklir PressAir coverage criteria.
    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:
      • Removed Antiemetic products.
      • Removed Anti-infective agents – Tetracycline antibiotic products.
      • Removed Psychotherapeutic Drugs – Miscellaneous products.
      • Removed Qbrexza.
      • Removed Bethkis.
      • Removed Tobi.
        • Above products now in standalone coverage policies.
      • Modified Spiriva Respimat criteria to allow for fulfillment of criteria if individual has or is using dual asthma therapy.
      • Updated covered inhaled corticosteroid alternatives to include Flovent (fluticasone).
      • Added Striverdi Respimat (olodaterol).
      • Added Arcapta Neohaler (indacaterol).
      • Updated Seebri Neohaler (glycopyrrolate) criteria.
      • Updated Tudorza Pressair (aclidinium) criteria.
        • Above two updates made with removal of Spiriva as a covered alternative.
      • Removed Serevent criteria:
        • Now preferred brand.
      • Added ProAir Digihaler coverage criteria.
      • Added Duaklir PressAir coverage criteria.
    Golimumab Intravenous – (M0007) Modified
    Hepatitis C – (1316) Modified
    • Important changes in coverage criteria:
      • Removed brands for Harvoni and Epclusa as preferred brands covered under IFP.
    Hereditary Angioedema (HAE) Therapy – (1019) Modified
    • Important changes in coverage criteria:
      • Added criteria to require generic icatibant before brand Firazyr for Standard/Performance/Value/Advantage plans.
      • Added re-authorization criteria for HAE agents (up to 6 months for initial, and up to 12 months for re-auth), and further defined “evidence of beneficial clinical response” bullet with “(for example, decrease in frequency of HAE acute attacks, decrease in HAE attack severity, decrease in duration of HAE attacks).”
      • Added standard specialist prescribing requirement criteria language, “Prescribed by or in consultation with an allergist/immunologist or a physician who specializes in the treatment of HAE or related disorders.”
    HIV Products – (P0050) Modified
    • Important changes in coverage criteria: Updated to support prior authorization on all HIV products except preferred products for adolescents and adults, applying to new starts only.
      • Policy previously applied to products with generic equivalents where the criteria was to first use generic equivalent before branded product.
    Immune Globulin – (5026) Modified
    • Important changes in coverage criteria:
      • Added coverage criteria for maintenance treatment of refractory myasthenia gravis.
      • Added three new products:
        • Asceniv.
        • Cutaquig.
        • Xembify
      • Added new strength: Cuvitru 10 g/50 mL.
      • Removed Carimune NF:
        • No longer available.
    Immunomodulators – Oral and Subcutaneous (Employer Group Benefit Plans) - (1805) Modified
    • Important changes in coverage criteria:
      • Added expanded FDA approved indications.
      • Revised Rinvoq to preferred brand for rheumatoid arthritis.
      • Added authorization and reauthorization duration of 12 months unless otherwise stated.
    Immunomodulators – Oral and Subcutaneous – (Individual and Family Plans – (1903) Modified
    • Important changes in coverage criteria:
      • Removed medical drugs and added them to standalone policy - Infliximab – (M0003) and Natalizumab for Chron’s Disease – (M0008) - to align with employer group coverage policies.
      • Added the following to preferred status from non-preferred.
        • Stelara.
        • Xeljanz.
        • Xeljanz XR.
      • Added step therapy for:
        • Actemra in polyarticular juvenile idiopathic arthritis (PJIA).
        • Enbrel for plaque psoriasis.
        • Otezla for psoriatic arthritis.
      • Revised the number of alternatives required for:
        • Crohn’s disease.
        • Plaque psoriasis.
        • Polyarticular juvenile idiopathic arthritis.
        • Psoriatic arthritis.
        • Rheumatoid arthritis.
        • Ulcerative colitis.
      • Added authorization and reauthorization duration of 12 months unless otherwise stated.
    Infliximab – (M0003) Modified
    Multiple Sclerosis Therapy - (1402) Modified
    • Important changes in coverage criteria:
      • Moved Aubagio from preferred product to non-preferred product for Employer Group Benefit Plans.
      • Added two new FDA approved multiple sclerosis therapies:
        • Mavenclad.
        • Mayzent.
    Opioid Therapy - (1704) Modified
    • Important changes in coverage criteria:
      • Expanded Employer Group Benefit Plans immediate-release opioid analgesics statement by restricting acute dental prescriptions to a three day supply.
      • Added injectable opioid analgesic criteria statement.
      • Extended current Employer Group immediate-release opioid analgesic seven day opioid naïve criteria to IFP.
    Natalizumab for Chron’s Disease – (M0008) Modified
    PCSK9 Inhibitors – (1509) Modified
    • Important changes in coverage criteria:
      • Revised criteria for Primary Hyperlipidemia (including Heterozygous Familial Hypercholesterolemia [HeFH]) to align with guideline updates and reviews (AHA/ACC and Familial Hypercholesterolemia Foundation).
      • Removed Kynamro:
        • Discontinued by manufacturer.
      • Added recommended dosing information to initial/re-authorization criteria for Praluent in HeFH patients undergoing LDL apheresis:
        • Based on FDA label update.
      • Added “Experimental, Investigational, Unproven” bullet point for concurrent use of PCSK9s with each other or lomitapide.
    Pegfilgrastim – (1320) Modified
    • Important change in coverage criteria:
      • Removed the step through Neulasta required for IFP formulary plans:
        • The referenced pegfilgrastim product and the biosimilars will be covered at parity on IFP formulary plans.
    Pulmonary Hypertension (PH) - (6121) Modified
    • Minor change in coverage criteria/policy:
      • Added A-rated generic step-through requirement for Adcirca (tadalafil)
    Tocilizumab Intravenous – (M0004) Modified
    Tolvaptan (Jynarque®) – (P0056) Modified
    • Important changes in coverage criteria:
      • Revised age to 18 years of age or older.
      • Removed requirement of documentation of rapidly progressive disease and added specialist requirement of prescribed by or in consultation with a nephrologist.
      • Revised glomerular filtration rate (GFR) requirement to state chronic kidney disease stage 2 – stage 4 (removed GFR of greater than or equal to 25).
      • Added reauthorization criteria that states the initial criteria were met at start of therapy.
    Unassigned Drug or Biologic Code Medical Precertification - (1701) Modified
    • Important change in coverage criteria:
      • Added ketamine injection coverage criteria.
    Vedolizumab – (M0005) Modified
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    • No updates for January 2020
    Policies Status Details
    Precertification Policies*
    • No updates for January 2020.
    Policies Status Details
    Reimbursement Policies*
    • No updates for January 2020.
    Policies Status Details
    ClaimsXten*
    Code Edit and Policy Guidelines
    • Important changes effective February 15, 2020:
      • ClaimsXten will be updated to First Quarter Knowledge Base content and NCCI Version 26.0 for all medical and behavioral claims we process.

    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.