Policy Updates July 2016

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective July 15, 2016:
Athletic Pubalgia Surgery – (0522) New
  • The two codes (49659 and 49999) in this policy were already implemented.
    • Both codes require medical necessity review and precertification.
Balloon Sinus Ostial Dilation for Chronic Sinusitis – (0480) New
  • Policy previously posted on April 15, 2016 to provide advance health care professional notification; is effective on July 15, 2016.
  • Important change in coverage:
    • Changed from covered to not covered for a subset of patients.
Comparative Genomic Hybridization Testing (Chromosomal Microarray Analysis) for Autism Spectrum Disorders, Developmental Delay, Intellectual Disability and Multiple Congenital Anomalies - (0493) Modified
  • Changes previously posted on April 15, 2016 to provide advance health care professional notification; are effective on July 15, 2016.
  • Important change in coverage:
    • Added policy statement and supporting disclaimer requiring genetic counseling.
  • Policy statement updates with no change in coverage:
    • Removed the words “or specified” from the title.
Electronic Stimulation Therapy and Devices – (0160) Modified
  • Unknown if change in coverage:
    • Added a not covered statement for percutaneous posterior tibial nerve stimulation (PTNS).
Genetic Testing for Hereditary Cancer Susceptibility Syndromes – (0518) Modified
  • Changes previously posted on April 15, 2016 to provide advance health care professional notification; are effective on July 15, 2016.
  • Important change in coverage:
    • Added policy statement and supporting disclaimer requiring genetic counseling.
  • Unknown if change in coverage:
    • Added gene-specific genetic testing criteria for CHEK2 and PALB2 genes.
  • Policy statement updates with no change in coverage:
    • Added wording under general criteria for coverage about the need for National Comprehensive Cancer Network™ (NCCN) category 1, 2A recommendations and/or other published, evidence-based management guidelines.
    • Removed condition- and syndrome-specific genetic testing criteria for which there are NCCN guidelines.
      • Added list of syndromes, genes affected, and applicable CPT codes.
    • Added wording under section for multi-gene testing about the need for NCCN category 1, 2A, and 2B guidelines and/or other published, evidence-based management recommendations.
Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias – (0517) Modified
  • Changes previously posted on April 15, 2016 to provide advance health care professional notification; are effective on July 15, 2016.
  • Important changes in coverage:
    • Added policy statement and supporting disclaimer requiring genetic counseling.
    • Changed criteria for dilated cardiomyopathy:
      • Now reflects that targeted single-gene or multi-gene panel testing is medically necessary for individuals who are candidates for an implantable or wearable cardioverter defibrillator.
Minimally Invasive Intradiscal/Annular Procedures and Trigger Point Injections – (0139) Modified
  • Policy statement updates with no change in coverage:
    • Changed denial rationale only for ultrasound-guided trigger point from not medically necessary (NMN) to experimental, investigational or unproven (EIU).
    • Clarified language for endoscopic procedures to include “cervical, thoracic, and lumbar”.
  • Unknown if change in coverage:
    • Added bullet for denial of “endoscopic, anterior cervical disc decompression (e.g., Cervical Deuk Laser Disc Repair [CPT code 22899])
Speech Therapy - (0177) Modified
  • Policy statement updates with no change in coverage:
    • Added clarifying statement for continuation of visits.
Strapping and Taping– (0512) Modified
  • Important changes in coverage:
    • Removed “initial” from the covered statement for strapping.
      • Subsequent strapping will be covered.
    • Added additional covered diagnosis to the strapping codes for ankle, foot, and toes.
  • Policy statement update with no change in coverage:
    • Added a “not covered for all other indications” statement.
Whole Exome and Whole Genome Sequencing – (0519) Modified
  • Changes previously posted on April 15, 2016 to provide advance health care professional notification; are effective on July 15, 2016.
    • Important changes in coverage:
      • Added policy statement and supporting disclaimer requiring genetic counseling.
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective July 15, 2016:
Medication Administration Site of Care – (1605) New
  • Supports the Specialty Care Options program.
Brand Name Drugs 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:
    • Removed Toujeo® and Tresiba® criteria.
      • Business decision to move to preferred brands.
Brand Name Drugs 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:
    • Aligned Levemir® criteria to approach used with Tresiba.
    • Added Tresiba interim criteria.
    • Updated Crestor brand to rosuvastatin:
      • Generic is now available for covered alternatives to Vytorin.
Eculizumab (Soliris®) - (1103) Modified
  • Important changes in coverage:
    • Removed diagnostic criteria for an ADAMTS-13 level for atypical hemolytic uremic syndrome (aHUS).
    • Added criteria to exclude diagnosis of thrombocytopenic purpura or no clinical improvement with a trial of plasma exchange for aHUS.
    • Modified criteria for meningococcal vaccine for aHUS.
Hepatitis C Therapy - (1316) Modified
  • Important changesin coverage:
    • Added coverage of Daklinza ™ plus Sovaldi for genotype 2 when ribavirin ineligible.
    • Added coverage of Daklinza plus Sovaldi plus ribavirin for individuals with genotype 2 and decompensated cirrhosis or post-liver transplant.
    • Added previously approved interim criteria for Daklinza plus Sovaldi for genotype 1 and Daklinza plus Sovaldi plus ribavirin for genotype 3 with cirrhosis, decompensated cirrhosis, or post-liver transplant.
    • Modified Harvoni criteria for genotype 1, prior sofosbuvir-experienced (specified prior use of Sovaldi plus ribavirin with or without pegylated interferon).
    • Added coverage of Harvoni for 24 weeks for genotypes 1 or 4 with decompensated cirrhosis and ribavirin ineligible.
    • Expanded treatment duration authorization for Sovaldi plus ribavirin to up to 24 weeks for genotype 2 and treatment-naïve with cirrhosis.
    • Removed coverage of Sovaldi plus ribavirin for genotype 4 and treatment-naïve.
    • Clarified coverage of Sovaldi plus ribavirin for up to 48 weeks for genotypes 1, 2, 3, or 4 with hepatocellular carcinoma awaiting liver transplant.
    • Added coverage of pegylated interferon plus ribavirin for genotypes 2, 3, 5, or 6 with severe renal impairment (creatinine clearance less than 30 mL/min.
    • Removed PegIntron due to manufacturer discontinuation/product unavailable.
Medication Assisted Treatment for Opioid Dependence - (1413) Modified
  • Important changes in coverage:
    • Added “solely” to the statement “the medication is not being used for pain management” to allow for treatment of individuals with concurrent chronic pain and opioid dependence.
    • Added criteria that opioid dependence medications should not be used concurrently with opioid analgesics.
Oncology Medications - (1403) Modified
  • Important changes in coverage:
    • Added criteria for Xtandi® (enzalutamide) to prefer use of Zytiga® (abiraterone) for individuals initiating therapy.
Pharmacy Prior Authorization - (1407) Modified
  • Important changes in coverage:
    • Added Cresemba® (isavuconazonium) criteria
      • FDA approved uses and recognized American Hospital Formulary Service (AHFS) off-label uses.
    • Removed Toujeo based on business decision.
Pulmonary Hypertension (PH) Therapy - (6121) Modified
  • Important changes in coverage:
    • Added Uptravi® (selexipag) criteria.
    • Eliminated age requirement in sildenafil/Revatio criteria.
    • Added statement indicating medications should be prescribed by specialist.
Secukinumab (Cosentyx) - (1512) Modified
  • Important changes in coverage:
    • Added statement that receipt of sampled product does not satisfy criteria requirements.
    • Added criteria for recently approved FDA indications of psoriatic arthritis and ankylosing spondylitis.
    • Added “not a candidate for” language for other prior therapies.
    • Added criteria that concurrent use of Cosentyx with other biologic therapies (anti-tumor necrosis factor [TNF] therapy or non-anti-TNF therapy) is EIU.
Step Therapy - (1109) Modified
  • Important changes in coverage:
    • Removed requirement of Tobi before Cayston from Emerging Step Therapy (B-Step Therapy) program.
Tocilizumab (Actemra®) - (1024) Modified
  • Important changes in coverage:
    • Added statement that receipt of sampled product does not satisfy criteria requirements.
    • Added “not a candidate for” language for other prior biologic therapies.
    • Modified examples provided for “not a candidate for” subcutaneous Acemtra® to physical impairment under criteria for intravenous Actemra.
Anti-Thymocyte Globulin Therapy – (5004) Retired
  • Business decision to remove from medical precertification.
Policies Status Details
Administrative Policies
No updates for July 2016
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Seventeen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
*Please log in to view these policies.
Policies Status Details
Precertification Policies*
Precertification List Modified
  • Important changes effective July 1, 2016.
    • Added 8 new Category III CPT Codes (0438T-0445T) and 8 new HCPCS codes (C9476, C9477, C9478, C9480, S3854, Q5102, Q9982 and Q9983) to precert.
R21 - Precertification Modified
  • Updated to include reference to Health Care Matters –Complete and Health Care Matters –Preferred as products requiring precertification.
Policies Status Details
Reimbursement Policies*
No updates for July 2016.
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
No updates for July 2016.
Policies Status Details
Policies with a Reduction in Coverage**
**The following policy updates, effective either July 15, 2016 or July 22, 2016 (see below), will result in a reduction of coverage. There were no additional policy updates that resulted in a reduction of coverage.

Drug Testing (0513)

For claims processed on or after July 15, 2016 for customers with a GWH-Cigna or “G” ID Card.

For claims processed on or after July 22, 2016 for all other customers with Cigna coverage.

    Claims billed with HCPCS G0482 or G0483 for more than eight units per date of service will be denied as medically unnecessary.

    We will add HCPCS G0481 to these claims to allow for eight units per date of service.


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.