Policy Updates July 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective July 15, 2017:
Genetic Testing for Hereditary Cancer Susceptibility Syndromes - (0518) Modified
  • Important change in coverage criteria:
    • Added coverage for testing for hereditary paraganglioma-pheochromocytoma (PGL/PCC) syndrome.
Tumor Profiling, Gene Expression Assays, and Molecular Diagnostic Testing for Hematology/Oncology Indications - (0520) Modified
  • Important change in coverage criteria:
    • Updated criteria for diagnostic testing for primary myelofibrosis.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy (drugs & biologics) coverage policies were modified effective July 15, 2017:
Canakinumab - (1110) Modified
  • Important changes in coverage criteria:
    • Added criteria (consistent with interim approach) for:
      • Familial Mediterranean fever (FMF)
      • Hyperimmunoglobulin D (Hyper-IgD) syndrome (HIDS)/mevalonate kinase deficiency (MKD)
      • Tumor necrosis factor (TNF) receptor associated periodic syndrome (TRAPS)
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, effective July 1, 2017:
    • Updated criteria (consistent with interim approach) for:
      • Jardiance
      • Synjardy/Synjardy XR
      • Glyxambi
    • Added criteria for:
      • metformin ER tablets (generic for Glumetza)
      • Gelnique (consistent with interim approach)
      • Adlyxin
      • Basaglar
    • Updated criteria for Belbuca:
      • Reflects generic availability of Butrans® (buprenorphine transdermal patch)
    • Updated criteria for Aplenzin, Wellbutrin XL, Cymbalta, Lexapro, and Pexeva® to reflect the availability of generic Pristiq
      • Removed requirement of brand Pristiq and added the generic, desvenlafaxine succinate ER, to the list of alternatives.
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, effective July 1, 2017:
    • Updated criteria for Vytorin (ezetimibe/simvastatin) to reflect generic availability.
    • Updated criteria (consistent with interim approach) for:
      • Jardiance
      • Synjardy/Synjardy XR
      • Glyxambi
    • Removed criteria (consistent with interim approach) for:
      • Farxiga
      • Xigduo
    • Added criteria for:
      • metformin ER tablets (generic for Glumetza)
      • Gelnique (consistent with interim approach)
      • Adlyxin
      • Basaglar
      • Updated criteria for Belbuca:
        • Reflects generic availability of Butrans (buprenorphine transdermal patch)
      • Updated criteria for Aplenzin, Wellbutrin XL, Cymbalta, Lexapro, and Pexeva to reflect the availability of generic Pristiq
        • Removed requirement of brand Pristiq and added the generic, desvenlafaxine succinate ER, to the list of alternatives.
Eculizumab - (1103) Modified
  • Important change in coverage criteria:
    • Added criteria requiring meningococcal vaccine for paroxysmal nocturnal hemoglobinuria (PNH).
Hydroxyprogesterone caproate injection - (1108) Modified
  • Important change in coverage criteria:
    • Removed Delalutin criteria based on business decision to remove from medical precertification.
Octreotide - (5015) Modified
  • Important change in coverage criteria:
    • Reinstated criteria for oncology uses.
Oncology Medications - (1403) Modified
  • Important change in coverage criteria:
    • Added criteria to not allow concomitant administration of Xtandi with Zytiga.
    • Removed Octreotide:
Policies Status Details
Cigna-eviCore Cobranded Imaging Guidelines
Updated 20 (Adult and Pediatric for each) Cigna-eviCore Cobranded Imaging Guidelines, effective July 14, 2017:
  • Abdomen
  • Cardiac
  • Chest
  • Head
  • Musculoskeletal
  • Neck
  • Pelvis
  • Peripheral Nerve Disorders (PND)
  • Peripheral Vascular Disease (PVD)
  • Spine
Policies Status Details
Administrative Policies
No updates for July 2017.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Nine 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 July 2017.
Policies Status Details
Reimbursement Policies*
Updates have been made to the following:
R27 Related Services Supplies Drugs and Equipment New

R12 Facility Routine Services, Supplies and Equipment

R15 Respiratory Services and Supplies

Modified
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
No updates for July 2017
Policies Status Details
Policies with a Reduction in Coverage
We are changing how we reimburse providers as follows:.

R27 Related Services, Supplies, Drugs, and Equipment

CP 0160 Electrical Stimulation Therapy and Devices

Effective July 9, 2017, we will implement a new policy, Related Services, Supplies, Drugs, and Equipment (R27), and deny reimbursement for supplies associated with Electrical Stimulation Therapy and Devices (0160) if the claim for the device was previously denied.

The update will apply to claims processed on or after July 9, 2017, whether the supplies are billed with the device or separately.

R12 Facility Routine Services, Supplies and Equipment

R15 Respiratory Services and Supplies

Effective July 24, 2017, and consistent with our reimbursement policies, we will not separately reimburse for point-of-care services performed by nursing and other ancillary staff at inpatient facilities. Point-of-care services are services provided at the patient bedside or near the site of patient care (for example, rapid diagnostic testing). These services are included in the reimbursement for inpatient room and board.

The update will apply to claims processed on or after July 24, 2017.


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.