Policy Updates July 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 Status Update to Coverage
Policies With a Reduction in Coverage
We are changing how we reimburse for the following policies:
Duplex Scan to Evaluate for Carotid Artery Stenosis (0542)

  • We will implement a new medical coverage policy, Duplex Scan to Evaluate for Carotid Artery Stenosis (0542), to review duplex scans for carotid artery stenosis screening for medical necessity. The affected Current Procedural Terminology (CPT®) code is 93880.
  • This policy is effective for dates of service beginning July 15, 2019.

Daily Routine and Supplies in Outpatient Settings

*Facility Routine Services, Supplies and Equipment (R12)

  • We will expand our current edits to deny claims for routine supplies provided in an outpatient setting. Routine supplies are included in the facility fee and are not separately reimbursable. This aligns with our Facility Routine Services, Supplies and Equipment (R12) reimbursement policy.
  • This update is effective for claims processed on or after July 15, 2019.

Facility Evaluation and Management (E&M)

*Facility Routine Services, Supplies and Equipment (R12)

  • We will update our Facility Routine Services, Supplies and Equipment (R12) reimbursement policy and deny claims for evaluation and management (E&M) services billed by a facility on a UB claim form. Only the E&M code will be denied. All other services on the claim will be reimbursed according to the terms of the customer’s benefit plan and the facility’s Agreement.
  • Note: Outpatient facilities, including oncology clinics, urgent care facilities, behavioral health care, emergency rooms, Veterans Affairs Medical Centers, and Maryland are excluded from this update.
  • This update is effective for claims processed on or after July 15, 2019.

Intraoperative Neurophysiological Monitoring (IONM) Studies

*Facility Routine Services, Supplies and Equipment (R12)

  • We will update our Facility Routine Services, Supplies and Equipment reimbursement policy (R12), and deny claims for intraoperative neurophysiological monitoring (IONM) studies and associated electrodiagnostic studies when billed with Place of Service (POS) codes 11 and 15.
  • POS code 11 is used to bill for services in an office setting. POS code 15 is used to bill for services provided in a mobile unit. IONM services are only reimbursable when provided in the same location where the surgery is being performed; i.e., an operating room setting.
  • This policy update is effective for claims processed on and after July 15, 2019.

Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis (0514)

  • We will update our Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis (0514) medical coverage policy to review sequencing-based non-invasive prenatal testing for medical necessity. The affected CPT codes are 81420, 81507, and 0009M.
  • This policy update is effective for dates of service beginning July 15, 2019.

Outpatient Code Editing

  • We will expand our current edits to apply outpatient code editing to additional contract types, including mixed percent off charges (POC) contract types.
  • As a reminder, we use ClaimsXten®, a market-leading, rules-based software application, to help expedite and improve the accuracy of medical and behavioral claims submitted on a Centers for Medicare and Medicaid Services (CMS) 1500 claim form and for certain claims submitted on a UB04 claim form.
  • This update is effective for claims processed on and after July 15, 2019.

Pneumatic Compression Devices and Compression Garments (0354)

  • In alignment with our current Pneumatic Compression Devices and Compression Garments (0354) medical coverage policy, we will deny pneumatic pump claims billed with International Classification of Diseases (ICD-10) code I87.1 as not medically necessary.
  • Additionally, we will deny claims billed with Healthcare Common Procedure Coding System (HCPCS) code E0676 as experimental, investigational, and unproven (EIU) for any indication in the home setting.
  • This update is effective for dates of service beginning July 15, 2019.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective July 15, 2019:
Angioplasty (Extracranial, Intracranial) and Endoluminal Flow Diverting Devices – (0545) New
  • Advance notification of policy effective October 15, 2019:
    • Addresses medical necessity of certain angioplasty procedures.
    • Will be implemented via precertification.
Duplex Scan to Evaluate for Carotid Artery Stenosis – (0542) New
  • Originally provided advance notification on April 18, 2019:
    • Identifies indications for which duplex scan is considered medically necessary in the evaluation of carotid artery stenosis.
Bariatric Surgery and Procedures – (0051) Modified
  • Important changes in coverage criteria:
    • Updated title - previously “Bariatric Surgery”.
    • Expanded coverage for subset of adolescents who meet coverage criteria.
    • Removed criterion from the “Reoperation and Revisional Bariatric Surgery (Adults)” section.

Genetic Testing for Hereditary Cancer Susceptibility Syndromes - (0518)

Modified
  • Important changes in coverage criteria:
    • Updated reference to mutation to reflect pathogeneic or likely pathogeneic variant.
    • Added policy statements related to germline testing following identification of a somatic pathogenic or likely pathogenic variant.
    • Updated criteria for germline genetic testing for CHEK2, PALB2 and prostate cancer.
Genetic Testing for Reproductive Carrier Testing and Prenatal Diagnosis - (0514) Modified
  • Originally provided advance notification of important changes in coverage criteria on May 18, 2019:
    • Implementing existing policy statements related to non-invasive prenatal testing (NIPT).
Headache and Occipital Neuralgia Treatment - (0063) Modified
  • Minor change in coverage criteria/policy:
    • Added “resection of the semispinalis capitis muscle” to existing experimental, investigational or unproven (EIU) policy statement.
Minimally Invasive Anti-Reflux Procedures and Peroral Endoscopic Myotomy (POEM) – (0019) Modified
  • Important changes in coverage criteria:
    • Updated title – previously “Endoscopic Anti-Reflux Procedures”.
    • Added peroral endoscopic myotomy (POEM) as EIU for all indications, including esophageal achalasia.
Nucleic Acid Pathogen Testing – (0530) Modified
  • Important change in coverage criteria/policy:
    • Updated title – previously “Diagnostic Microbe Testing for Sexually Transmitted Diseases (STDs)”.
    • Expanded scope to address indications for testing in addition to testing for STDs.
    • Removed treponemal and nontreponemal (syphilis) antibody testing from scope and from claim editing.
    • Added additional diagnosis codes as medically necessary.
    • Updated criteria to reflect coverage criteria for symptomatic and asymptomatic individual.
Pneumatic Compression Devices and Compression Garments - (0354) Modified
  • Originally provided advance notification of important changes in coverage criteria on April 15 2019:
    • Removed ICD10 code I87.1 compression of vein, from covered diagnosis codes.
      • Not covered for use with pneumatic compression device.
    • Removed HCPCS Code E0676 Intermittent limb compression device (includes all accessories), from covered diagnosis codes.
Tests for the Evaluation of Preterm Labor and Premature Rupture of Membranes - (0099) Modified
  • Minor changes in coverage/policy:
    • Changed evaluation to screening in existing policy statement.
    • Added asymptomatic women to existing bacterial vaginosis (BV) testing criterion.
Transcatheter Heart Valve Procedures – (0501) Modified
  • Important change in coverage criteria:
    • Added policy statement for percutaneous mitral valve repair for a subset of patients with degenerative mitral regurgitation (MR).
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • No new or updated policies for July 2019.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Originally provided advance notification on May 1, 2019, of updates to the followingCigna-eviCore Cobranded Imaging guidelines, effective August 1, 2019: Modified
  • Adult Abdomen
  • Pediatric Abdomen
  • Adult Cardiac
  • Adult Musculoskeletal
  • Adult Spine
  • Adult Peripheral Vascular Disease (PVD)
Updated the Hip Replacement Arthroplasty (CMM 313) Cigna-eviCore Cobranded Comprehensive Musculoskeletal Management (CMM) guidelines: Modified
  • Added clarification that failure of three months of provider-directed, non-surgical management is not required for individuals with avascular necrosis stage III or greater with collapse of the femoral head under partial and total hip replacement policy statements.
Policies Status Details
Administrative Policies
Preventive Care Services – (A004) Modified
  • Important changes, effective July 1, 2019:
    • Screening for Syphilis:
      • Added CPT code 0064U.
    • Wellness Codes in Code Group 1:
      • Added diagnosis codes Z20.1, Z20.2, Z20.5, and Z20.6.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective July 1, 2019:
Antitussives - (P0083) New
  • Supports coverage requirements for selected antitussive products.
Budesonide (Uceris®:) - (P0084) New
  • Supports coverage requirements for selected budesonide products.
Glycopyrronium topical cloth – (P0063) New
  • Supports coverage requirements for Qbrexza.
Nafarelin acetate - (P0082) New
  • Supports coverage requirements for Synarel.
Oral Antihistamines - (P0087) New
  • Supports coverage requirements for oral antihistamines.
Sarecycline – (P0092) New
  • Supports coverage requirements for Seysara.
Sodium Oxybate – (P0075) New
Carbidopa and levodopa enteral suspension - (1606) Modified
  • Minor changes in coverage criteria:
    • Clarified levodopa requirements to be oral levodopa
Dupilumab - (1810) Modified
  • Important changes in coverage criteria:
    • Updated to conform to 2019 template standards.
    • Added specialist requirement for all indications to increase adherence to guidelines.
    • Added attestation of asthma diagnosis as evidenced by pulmonary function tests to address concerns undocumented asthma diagnosis from providers.
    • Modified blood eosinophil level to expand coverage to individuals with a greater than or equal to 150 cells/microliter level within the past 6 weeks.
    • Added the descriptor "maintenance" before systemic corticosteroids to clarify intent of systemic corticosteroids example within the systemic immunomodulator criterion under Atopic Dermatitis.
    • Added initial authorization duration of up to six months for all indications:
      • Generally thought to be an adequate amount of time to observe clinical benefit for all conditions and this duration aligns closely with results observed for primary endpoints in clinical trials.
    • Added reauthorization duration of up to 12 months for all indications as per current coverage policy standards.
    • Added standard reauthorization criteria for Dupixent’s use for Atopic Dermatitis as per current coverage policy standards.
    • Removed Chronic Sinusitis and Nasal Polyposis from EIU uses section, pending FDA approval.
Golimumab Intravenous (Employer Group Benefit Plans) – (M0007) Modified
  • Important changes in coverage criteria:
    • Added example of scenario that an individual is not a candidate for stepping through either Verzenio or Ibrance to Kisqali/Kisqali Femara Co-Pack coverage criteria language.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Added example of scenario that an individual is not a candidate for stepping through either Verzenio or Ibrance to Kisqali/Kisqali Femara Co-Pack coverage criteria language.
Opioid Therapy - (1704) Modified
  • Minor changes in coverage criteria:
  • Clarified medication-assisted treatment requirement (MAT therapy) only applicable to methadone criteria.
  • Added criteria for Apadaz.
Viscosupplementation for Osteoarthritis - (1405) Modified
  • Minor changes in coverage criteria:
  • Added Synojoynt and TriVisc as non-preferred brands.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • One policy updated for July 2019.
Policies Status Details
Precertification Policies*
  • No updates for July 2019.
Policies Status Details
Reimbursement Policies*
  • No updates for July 2019.
Policies Status Details
ClaimsXten*
  • No new or updated policies for July 2019.

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.