Policy Updates July 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
We are changing how we reimburse for the following policies:
  • There were no additional changes made in July 2020 that resulted in a reduction in coverage.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective July 15, 2020:
Site of Care: High-Tech Radiology – (0550) New
  • Originally scheduled to be effective April 15, 2020.
  • High-tech radiology site of care pilot for fully insured and Cigna employer account now effective August 1, 2020.
    • Policy based on standard of care.
    • Will be used by eviCore.
Allergy Testing and Non-Pharmacologic Treatment - (0070) Modified
  • Important changes in coverage criteria:
    • Added bullet to existing experimental, investigational, unproven (EIU) policy statement for bead-based epitope assay (BBEA) for the diagnosis or management of allergic disease.
    • Clarified intradermal testing is not used to diagnose food allergies.
    • Clarified oral immunotherapy for food sensitivity is EIU unless the use is approved by the FDA.
Bariatric Surgery and Procedures - (0051) Modified
  • Minor changes in coverage criteria/policy:
    • Clarified examples of major complications.
Fetal Surgery - (0175) Modified
  • Minor changes in coverage criteria/policy:
    • Added congenital pulmonary airway malformation (CPAM) as indication for fetal thoracoamniotic shunt placement.
Minimally Invasive Spine Surgery Procedures and Trigger Point Injections - (0139) Modified
  • Important changes in coverage criteria:
    • Removed dry needling content from policy statement and background:
      • Addressed in several Cigna-American Specialty Health (ASH) cobranded Clinical Practice Guidelines (CPGs).
    • Added bone marrow concentrate to existing intradiscal injections bullet.
Scrotal Ultrasound - (0548) Modified
  • Advance notification of important changes in coverage criteria, effective September 15, 2020:
    • Added epididymal cyst to existing policy statement.
    • Added suspected inguinal hernia (occult) to existing policy statement.
    • Added ICD10 codes as covered to procedure-to-diagnosis (PXDX) edit logic:
      • C62.10 - C63.12 - Malignant neoplasm (descended testis, epididymis, spermatic cord)
      • N50.0 - Atrophy of testis
      • N50.1 - Vascular disorders of male genital organs
      • N50.3 - Cyst of epididymis
      • K40.00- K40.91 - Inguinal hernia.
        • No specific code for occult or suspected inguinal hernia.
Transcranial Magnetic Stimulation - (0383) Modified
  • Important changes in coverage criteria:
    • Reformatted for clarification regarding failure of two or more trials of antidepressant medications.
Vision Therapy/Orthoptics - (0221) Retired
  • No longer has business value; therefore, will no longer be maintained.
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Cognitive Rehabilitation – (CPG 270) Modified
  • Updated with no change in coverage.
Patient Assessments: Medical Necessity Decision Assist Guideline for Evaluations and Re-evaluations – (CPG 111) Modified
  • Updated:
    • Not a standard policy; is a listing and description of the evaluation and re-evaluation codes.
    • Removed information regarding consultation codes:
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Gastrointestinal Endoscopic Procedure Esophagogastroduodenoscopy (GED) guideline Modified
  • Originally provided advance notification on April 15, 2020:
    • Added qualifying physical and lab findings by which gastrointestinal (GI) bleeding and iron deficiency should be demonstrated.
    • Added criteria for the following:
      • Epigastric pain suggesting pancreatic or biliary source.
      • Failure of antisecretory medical therapy.
      • Appropriate cardiac workup for noncardiac chest pain.
      • Absence of dysplasia based on risk stratification.
      • Added follow up to hyperplastic polys with dysplasia.
      • Evaluating extra-esophageal symptoms of gastroesophageal reflux disease (GERD).
    • Added new indication for an EGD and atrophic gastritis.
High-Tech Radiology (HTR or Imaging) guidelines Modified
  • Updated the following guidelines, effective July 31, 2020:
    • Abdomen Adult
    • Breast Adult
    • Cardiac Adult
    • Chest Adult
    • Head Adult
    • Head Pediatric
    • Musculoskeletal Adult
    • Neck Adult
    • Pelvis Adult
    • Peripheral Vascular Disorders Adult
    • Spine Adult
  • Advance notification of updates the following guideline, effective October 1, 2020:
    • Chest Adult:
      • Updated and added new section 13.2: Coronavirus Disease (COVID-19); addresses chest CT scans.
Radiation Therapy guidelines Modified
  • Important changes, effective July 1, 2020 include:
    • Breast Cancer:
      • Statement for palliative care divided into potentially curative and truly palliative.
    • Proton Beam Cancer:
      • Broadened coverage for PBT for Stage III non-small cell lung cancer (NSCLC).
    • Changes made in fractionation for clarification.
Radiation Therapy guidelines Modified
  • Important changes effective August 1, 2020:
    • Added one new guideline for vulvar cancer.
    • Removed Xofigo from bone metastases guideline to be a standalone guideline.
    • Updated the following guidelines changes in coverage
      • Image-guided radiation therapy (IGRT):
        • Use of IGRT is based on medical necessity for the specific diagnoses.
        • A requirement from the vendor does not support the medical necessity of IGRT.
      • Pancreatic:
        • Neoadjuvant radiation therapy is no longer medically necessary for patients with disease that is fully resectable.
      • Small Cell Lung Cancer:
        • Fractions allowed for palliation were decreased from 15 to 10.
Radiation Therapy guidelines Modified
  • Important changes effective September 24, 2020:
    • Breast Cancer:
      • Changes made in fractionation for whole breast irradiation following breast-conserving surgery.
    • Prostate Cancer:
      • Removed three-dimensional conformal radiation therapy (3DCRT) coverage for definitive treatment of low- and intermediate-risk disease.
Policies Status Details
Administrative Policies
  • No updates for July 2020.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective July 1, 2020:
Supports pharmacy prior authorization requirements. New
Supports pharmacy prior authorization and medical necessity criteria requirements. New
Supports medical necessity review of noncovered items. New
Modafinil / Armodafinil for Employer Group Plans – (2019) New
  • Created new policy using information from Modafinil / Armodafinil for Individual and Family Plans – (1501) to reflect separation of employer group and individual and family plan policy numbers.
  • Added coverage for adjunctive/augmentation treatment for depression, excessive daytime sleepiness (EDS) due to myotonic dystrophy and idiopathic hypersomnia.
  • Updated narcolepsy criteria statement:
    • Aligned with criteria for Xyrem and Sunosi.
  • Updated obstructive sleep apnea/hypopnea syndrome (OSAHS) criteria statement:
    • Aligned to FDA labeled imitations of use.
  • Updated shift work sleep disorder (SWSD) criteria statement:
    • Requires documentation of SWSD diagnosis and requires minimum of five overnight shifts per month (pivotal trial inclusion requirement) and AASM diagnostic recommendations.
  • Added specialist prescribing requirement.
  • Added reauthorization time limit of 12 months.
  • Updated EIU statement.
Botulinum Therapy - (1106) Modified
  • Important changes in coverage criteria:
    • Added statement detailing medical necessity requirements for concurrent use of a calcitonin gene-related peptide receptor antagonist and Botox, including removal of use from EIU section.
Burosumab-twza – (M0002) Modified
  • Important changes in coverage criteria:
    • Removed age requirement bullet due to FDA approved labeling changes:
      • Indication now down to six months of age.
    • Added tubular reabsorption of phosphate corrected for glomerular filtration rate as an option to document diagnosis:
      • Added due to clinical literature support.
    • Added specialist requirement.
    • Added baseline serum phosphorous level below normal for age range.
    • Added to EIU section:
      • Chronic kidney disease (CKD)
      • Severe renal impairment or end-stage renal disease
      • Epidermal nevus syndrome (ENS)
      • Tumor-induced osteomalacia (TIO)
Calcitonin Gene-Related Peptide (CGRP) Inhibitors - Preventative Migraine Treatment for Employer Group Plans - (1813) Modified
  • Important changes in coverage criteria:
    • Simplified preventative treatment statement.
    • Simplified prerequisite product approach:
      • No longer separating episodic and chronic migraine alternatives.
    • Removed triptans, for menstrual migraine, from list of migraine prophylaxis prerequisite options.
    • Added Botox, as an option, to list of migraine prophylaxis prerequisite options.
    • Removed Botox as a required step for Ajovy and Emgality on the value formulary:
      • There is currently no guidance to support sequencing either Botox before a CGRP, or vice versa.
    • Updated Emgality cluster headache statement with addition guideline recommending zolmitriptan nasal spray as prerequisite option.
    • Added Vyepti criteria:
      • Requires a step through use of a triptan.
    • Added Vyepti dose management requirement.
    • Added statement detailing medical necessity requirements for concurrent use of CGRP inhibitor and Botox.
    • Updated cluster headache initial and reauthorization intervals to three months and six months, respectively.
    • Removed concomitant use of calcitonin gene-related peptide receptor antagonist and Botox, including removal of use from EIU section.
Calcitonin Gene-Related Peptide (CGRP) Inhibitors – Acute Migraine Treatment - (2011) Modified
  • Important changes in coverage criteria:
    • Moved the no concurrent use with other CGRP inhibitors statement to the EIU statement:
      • Updated to only exclude use with other CGRP inhibitors indicated for acute treatment of migraine.
    • Decreased prerequisite requirements for Nurtec and Ubrelvy to one triptan:
      • Responsive to business decision to prefer both Nurtec and Ubrelvy.
Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List – (1601) Modified
  • Minor changes in coverage criteria/policy, effective July 15, 2020:
    • Removed proton pump inhibitors and moved to Proton Pump Inhibitors – (P0122).
    • Removed nasal steroids and combination product (Dymista) and moved to Nasal Steroids and Combinations – (P0121).
    • Added levalbuterol 45mcg inhaler to list of covered preferred alternatives for Proventil and Xopenex to be consistent throughout the policy.
    • Updated Spiriva Respimat 1.25mcg criteria for the add-on treatment of uncontrolled asthma.
    • Added coverage criteria for Halog topical solution.
Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List – (1602) Modified
  • Minor changes in coverage criteria/policy, effective July 15, 2020:
    • Removed nasal steroids and combination product (Dymista) and moved to Nasal Steroids and Combinations – (P0121).
    • Added levalbuterol 45mcg inhaler to list of covered preferred alternatives for Proventil and Xopenex to be consistent throughout policy.
    • Updated Spiriva Respimat 1.25mcg criteria for add-on treatment of uncontrolled asthma.
    • Added coverage criteria for Halog topical solution.
Esketamine - (M0010) Modified
  • Important changes in coverage criteria:
    • Decreased initial time limit to one month.
    • Decreased reauthorization time limit to three months.
    • Updated EIU statement by excluding use in bipolar disorder:
      • Individuals with bipolar disorder were excluded from pivotal clinical trials.
Eteplirsen - (1702) Modified
  • Minor changes in coverage criteria/policy:
    • Updated genetic testing requirement to clarify intent.
    • Updated EIU statement excluding concurrent use with Vyondys 53.
Hereditary Angioedema (HAE) Therapy – (1019) Modified
  • Minor changes in coverage criteria/policy:
    • Added requirement of icatibant for Berinert, Kalbitor, and Ruconest:
      • Applies to new starts only.
      • Applies to employer groups and individual and family plans (IFP).
      • Responsive to business decision.
Naloxone - (P0017) Modified
  • Minor changes in coverage criteria/policy, effective July 15, 2020:
    • Removed quantity limitation:
    • Updated Evzio prerequisite requirements:
      • Added a step through the generic, in addition to the currently required Narcan step.
Oncology Medications - (1403) Modified
  • Minor changes in coverage criteria/policy:
    • Reformatted coverage criteria stem:
      • No impact to intent of language.
    • Added to medical precertification table:
      • Jelmyto (mitomycin)
      • Darzalex Faspro (daratumumab and hyaluronidase-fihj)
    • Added to pharmacy benefit table:
      • Retevmo (selpercatinib)
      • Tabrecta (capmatinib)
      • Qinlock (ripretinib).
Pyrimethamine – (P0012) Modified
  • Minor changes in coverage criteria/policy:
    • Revised how isosporiasis is referred to, without change to criterion intent.
    • Added criterion requiring a step through generic formulation before brand Daraprim:
      • Responsive to business strategy.
    • Listed out malaria as specific EIU use consistent with CDC guidelines:
      • No longer recommending pyrimethamine for malaria treatment or prophylaxis due to widespread resistance of Daraprim worldwide.
Somatropin – (4012) Modified
  • Minor changes in coverage criteria/policy:
    • Clarified criteria for auxologic and diagnostic evaluation in children.
    • Removed from small for gestational age (SGA) criteria “Absence of chromosomal anomalies unless otherwise specified as covered.”
    • Modified Turner Syndrome criteria to simplify auxologic evaluation to be only pretreatment height less that 5th percentile for age in addition to confirmation of diagnosis by genetic testing.
Step Therapy - (1109) Modified
  • Minor changes in coverage criteria/policy:
    • Added the following diabetic medications to the metformin-first step therapy program:
      • Adlyxin
      • Byetta
      • Bydureon
      • Farxiga
      • Glyxambi
      • Invokana
      • Invokamet/Invokamet XR
      • Januvia
      • Janumet/Janumet XR
      • Jardiance
      • Kombiglyze XR
      • Onglyza
      • Ozempic
      • Qtern
      • Rybelsus
      • Steglatro
      • Steglujan
      • Segluromet
      • Synjardy/Synjardy XR
      • Trulicity
      • Victoza
      • Xigduo XR
    • Added clinical exception criteria for the metformin-first step therapy program.
Step Therapy - Standard Prescription Drug Lists (Employer Group Plans) - (1801) Modified
  • Minor changes in coverage criteria/policy:
    • Added the following diabetic medications to the metformin-first step therapy program:
      • Byetta
      • Bydureon
      • Farxiga
      • Glyxambi
      • Invokamet/Invokamet XR
      • Invokana
      • Janumet/Janumet XR
      • Januvia
      • Jardiance
      • Kombiglyze XR
      • Onglyza
      • Ozempic
      • Qtern
      • Rybelsus
      • Steglatro
      • Segluromet
      • Synjardy/Synjardy XR
      • Victoza
      • Xigduo XR
    • Added clinical exception criteria for the metformin-first step therapy program.
Step Therapy – Value Prescription Drug Lists (Employer Group Plans) - (1802) Modified
  • Minor changes in coverage criteria/policy:
    • Added the following diabetic medications to the metformin-first step therapy program:
      • Byetta
      • Bydureon
      • Farxiga
      • Glyxambi
      • Janumet/Janumet XR
      • Januvia
      • Jardiance
      • Ozempic
      • Rybelsus
      • Segluromet
      • Steglujan
      • Synjardy/Synjardy XR
      • Victoza
      • Xigduo XR
    • Added clinical exception criteria for the metformin-first step therapy program.
Step Therapy - Legacy Prescription Drug Lists (Employer Group Plans) - (1803) Modified
  • Minor changes in coverage criteria/policy:
    • Added the following diabetic medications to the metformin-first step therapy program:
      • Adlyxin
      • Byetta
      • Bydureon
      • Farxiga
      • Glyxambi
      • Invokana
      • Invokamet/Invokamet XR
      • Janumet/Janumet XR
      • Januvia
      • Jardiance
      • Kombiglyze XR
      • Onglyza
      • Ozempic
      • Qtern
      • Rybelsus
      • Segluromet
      • Steglujan
      • Steglatro
      • Synjardy/Synjardy XR
      • Trulicity
      • Victoza
      • Xigduo XR
    • Added clinical exception criteria for the metformin-first step therapy program.
Topical Vitamin D Analogs – (P0077) Modified
  • Minor changes in coverage criteria/policy:
    • Revised brand Taclonex suspension criteria to include requirement for step through the AB-generic formulation calcipotriene/betamethasone.
Transmucosal Fentanyl - (1018) Modified
  • Minor changes in coverage criteria/policy:
    • Added requirement for individual to remain on around-the-clock opioid therapy:
      • Aligned to FDA labels.
    • Removed Subsys as required step for Abstral, Actiq, Fentora and Lazanda and added a step through generic transmucosal fentanyl lozenge to the Subsys criteria.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • Two policies were updated for July 2020
Policies Status Details
Precertification Policies*
  • No updates for July 2020.
Policies Status Details
Reimbursement Policies*
  • No updates for July 2020.
Policies Status Details
ClaimsXten*
Code Edit and Policy Guidelines Modified
  • Important changes effective August 16, 2020:
    • ClaimsXten will be updated to Third Quarter Knowledge Base content and NCCI Version 26.2 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.