Policy Updates July 2018

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 Status Update to Coverage
Policies with a reduction in coverage
We are changing how we reimburse for the following policies:

Transcatheter Ablation for the Treatment of Supraventricular Tachycardia (SVT) – (0529)

Uniform Billing Editor (UBE)
  • UBE provides detailed information about Centers for Medicare & Medicaid Services (CMS) UB billing requirements, including a list of revenue codes that require a Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) code.
  • We will expand the revenue code list to include additional revenue codes not listed under the CMS UB billing requirements. This change is effective for claims processed on or after July 15, 2018.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective July 15, 2018:
Transcatheter Ablation for the Treatment of Supraventricular Tachycardia (SVT) – (0529) New
  • Advance notification originally provided on April 1, 2018, with effective date of July 1, 2018.
    • Addresses transcatheter ablation for the treatment of supraventricular tachycardia in adults.
    • Added CPT code 93653 to precertification.
Bariatric Surgery - (0051) Modified
  • Important change in coverage criteria:
    • Updated policy statement about previous weight loss attempt.

Diaphragmatic/Phrenic Nerve Stimulation - (0391)

Modified
  • Important change:
    • Added “including central sleep apnea” to existing not covered policy statement.
Genetic Testing for Hereditary Cancer Susceptibility Syndromes - (0518) Modified
  • Important changes in coverage criteria:
    • Updated genetic testing criteria for von Hippel-Lindau (VHL) syndrome:
      • Removed requirement individual must have two VHL-related lesions or a 1st, 2nd or 3rd degree blood relative with VHL.
    • Added new criteria for germline genetic testing for:
      • Individuals with early stage, non-metastatic prostate cancer.
      • BRCA1, BRCA2, ATM, PALB and FANCA mutations for individuals with localized stage III, regional or metastatic prostate cancer.
Genetic Testing for Hereditary and Multifactorial Conditions - (0052) Modified
  • Advance notification of important changes in coverage criteria, effective October 15, 2018:
    • Removed CPT codes 81440 and 0001U from precertification.
      • Added both codes to not medically necessary (NMN) batch.
Minimally Invasive Intradiscal/Annular Procedures and Trigger Point Injections – (0139) Modified
  • Important changes in coverage criteria:
    • Added language to existing not covered policy statements for “targeted” disc decompression and “targeted” percutaneous laser disc decompression.
    • Added reference to “radiofrequency thermocoagulation nucleoplasty (RFTC)” to existing not covered policy statement.
    • Added examples in parenthetical to the intradiscal injection not covered policy statement.
Omnibus Codes – (0504) Modified
Pharmacogenetic Testing - (0500) Modified
  • Advance notification of important changes in coverage criteria, effective October 15, 2018:
    • Removed CPT code 81283 from precertification
      • Added to NMN batch.
Tumor Profiling, Gene Expression Assays, and Molecular Diagnostic Testing for Hematology/Oncology Indications - (0520) Modified
  • Advance notification of important changes in coverage criteria, effective October 15, 2018:
    • Removed three CPT codes (0012M, 0013M, 0009U and 0026U) from precert.
      • Added codes to experimental, investigational and unproven (EIU) batch
    • Removed CPT code 81327 from precert.
      • Added to NMN batch.
Vitamin D Testing - (0526) Modified
  • Important changes in coverage criteria::
    • Revised policy statement criteria.
    • Added appendix of diagnoses or conditions associated with Vitamin D deficiency.
      • No change in coverage.
Whole Exome and Whole Genome Sequencing – (0519) Modified
  • Advance notification of important changes in coverage criteria, effective October 15, 2018:
    • Removed CPT code 0036U from precert.
      • Added to EIU batch.
Cognitive Rehabilitation – (0124) Retired
Percutaneous Alcohol Septal Ablation for Hypertrophic Cardiomyopathy - (CP 0090) Retired
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Unless otherwise noted, the following medical coverage policies were modified effective July 15, 2018:
Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations - (CPG 111) New
Cognitive Rehabilitation - (CPG 270) New
Policies Status Details
Cigna-eviCore Cobranded Guidelines
  • No updates for July 2018.
Policies Status Details
Administrative Policies
Preventive Care Services – (A004) Modified
  • Updated screening services and coding table, effective July 1, 2018:
    • Colorectal Cancer Screening
      • Added CPT codes 99152, 99153, 99156, 99157, and HCPCS code G0500
    • Routine Immunizations
      • Added CPT codes 90660 and 90672.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective July 15, 2018:
Eculizumab - (1103) Modified
  • Important changes in coverage criteria:
    • Updated indication name from atypical hemolytic uremic syndrome (aHUS) to complement-mediated hemolytic uremic syndrome (atypical hemolytic uremic syndrome).
      • No change in criteria intent.
    • Removed meningococcal vaccine requirement from the aHUS and PNH coverage statements.
      • Information on the FDA vaccine recommendation can be found in the background.
    • Incorporated interim criteria for generalized Myasthenia Gravis (gMG):
      • Increased initial authorization and reauthorization intervals to allow for complete dose titration and an adequate interval for the prescriber.
      • Added exclusion statement prohibiting a thymectomy in previous 12 months.
    • Added initial and reauthorization statements requiring a positive clinical response to each indication criteria statement.
    • Updated EIU statement with those indications from the background and removed STEC-HUS.
Oncology Medications - (1403) Modified
  • Important change in coverage criteria:
    • Added specific criteria to Kymriah for diffuse large B-cell lymphoma (DLBCL).
Pharmacy Prior Authorization - (1407) Modified
  • Important change in coverage criteria:
    • Updated therapeutic alternative language.
    • Added hyperlink for providers to search for specific patients to view their covered medications.
Pulmonary Hypertension - (6121) Modified
  • Important changes in coverage criteria:
    • Added pediatric coverage language and split criteria in to “adult and pediatric” and “adult” only coverage.
    • Clarified language noting other therapies may be used for pulmonary hypertension management that are not included as they require medical necessity review.
    • Added absence of congestive heart failure caused by reduced ejection left ventricular ejection to epoprostenol products’ criteria.
    • Added “not medically necessary for the treatment of” as Tracleer was shown to be ineffective for treatment of congestive heart failure with left ventricular dysfunction.
Quantity Limitations - (1201) Modified
  • Important changes in coverage criteria:
    • Corrected quantity limits for:
      • Daliresp
      • Banzel
    • Added quantity limits for:
      • Dificid
      • Kalydeco
      • Orkambi
      • Symdeko
      • Byetta
      • Adlyxin
Unassigned Drug or Biologic Code Medical Precertification - (1701) Modified
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for July 2018.
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
Code Edit and Policy Guidelines Modified
  • Advance notification of important changes, effective August 18, 2018:
    • ClaimsXten will be updated to Third Quarter Knowledge Base content and NCCI Version 24.2 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.