Policy Updates July 2022

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Policies Update to Coverage
Policies With a Reduction in Coverage
  • There were no additional changes made in July 2022 that resulted in a reduction in coverage.
Policies Status Details
Medical Coverage Policies
  • The information in this section is effective July 15, 2022, unless otherwise noted:
Bariatric Surgery and Procedures – (0051) Modified
  • Important changes in coverage criteria:
    • Minor grammatical edits/corrections, including clarifying procedure names.
    • Removed gastroplasty (stomach stapling) from policy statement:
      • Obsolete procedure.
    • Moved loop gastric bypass to the line with mini-gastric bypass.
    • Added heading for endoscopic bariatric surgery procedures:
      • Listed endoscopic procedures under heading.
      • Moved Natural Orifice Transluminal Endoscopic Surgery (NOTES) under header.
    • Simplified criteria about weight loss for a revision procedure.
Genetic Testing for Hereditary Cancer Susceptibility Syndromes – (0518) Modified
  • Important changes in coverage criteria:
    • Removed criteria due to differences in variant interpretation between labs and differences in interpretation between germline and somatic settings.
    • Added criteria for germline genetic testing as outlined in the National Comprehensive Cancer Network (NCCN) guidelines:
      • Myelodysplastic syndromes and acute myeloid leukemia.
Minimally Invasive Spine Surgery Procedures and Trigger Point Injections – (0139) Modified
  • Minor changes in coverage criteria/policy:
    • Removed two codes under experimental, investigational or unproven (EIU) policy statement.
Omnibus Codes – (0504) Modified
  • Minor changes in coverage criteria/policy:
    • Reviewed the following sections with no clinical changes:
      • Ophthalmology.
      • Otolaryngology.
      • Other (re: breast cancer-related lymphedema).
    • Added brand names to comments section of EIU table.
    • Alphabetized sections in background.
    • Added new CPT code 0715T (percutaneous transluminal coronary lithotripsy).
    • Removed acoustic cardiography-related content.
    • Removed CPT code 88749 (Unlisted in vivo [e.g. transcutaneous] laboratory service, used to report skin advanced glycation endproducts [AGE] measurement by multi-wavelength fluorescent spectroscopy).
      • There is no longer a business need to review.
Phototherapy, Photochemotherapy, and Excimer Laser Therapy for Dermatologic Conditions – (0031) Modified
  • Important change in coverage criteria:
    • Changed position on treatment of alopecia areata from cosmetic/not medically necessary (NMN) to EIU.
Tests for the Evaluation of Preterm Labor and Premature Rupture of Membranes – (0099) Modified
  • Important changes in coverage criteria:
    • Divided policy statement into two sections based on specific indication of the test.
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Chiropractic Care – (CPG278)

Occupational Therapy – (CPG155)

Physical Therapy – (CPG135)		 Modified
  • Advance notification of important changes in coverage criteria, effective October 15, 2022:
    • Added statement to the not medically necessary section noting that treatment visits beyond one hour per day, per provider are not medically necessary.
Cognitive Rehabilitation – (CPG270) Modified
  • Minor change in coverage criteria/policy:
    • Added disclaimer addressing state mandates.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Comprehensive Musculoskeletal Management (CMM) guidelines Modified
  • Important changes, effective July 29, 2022, for Medicare plans only:
    • Removed 105 eviCore musculoskeletal codes from precertification

    • Important changes to the interventional pain CMM guidelines posted on April 1, 2022, effective August 1, 2022:
      • CMM 204 Prolotherapy:
        • No changes.
      • CMM 203 Sacroiliac Procedures and
      • CMM 210 Implantable Intrathecal Drug Delivery Systems and
      • CMM 208 Radiofrequency Ablations/ Denervations:
        • Editorial /formatting changes.
      • CMM 209 Regional Sympathetic Blocks:
        • Updated to allow ultrasound guidance for imaging performed with stellate ganglion blocks.
        • Updated CRPS section:
          • Updated to require only three categorical symptoms for CRPS versus four (consistent with Budapest criteria).
          • Added criteria for “absence of other diagnoses concordant with present symptoms”.
          • Updated to require failure of at least six months of comprehensive management.
          • Updated to note coverage limited “only to extremities”.
          • Added not medically necessary conditions for:
            • Injectates other than anesthetic.
            • Blocks without use of imaging guidance.
            • Diagnosis of CRPS other than extremities.
        • Added EIU position for RFA and chemical neurolysis.
      • CMM 201 Facet Joint Injections:
        • Editorial/formatting changes for consistency with related guidelines.
        • Updated definitions for clarity.
        • Added requirement for at least 80 percent relief to confirm validity for a second diagnostic injection.
          • o No change to intent.
        • Clarified criteria for pain to “at least 3 months” consistent with “chronic”.
        • Added to not medically necessary section:
          • Repeat injection in the absence of at least 50 percent relief for at least 12 weeks and no other obvious cause is suspected.
      • CMM 200 Epidural Injections:
        • Editorial/formatting changes for consistency across all guidelines.
        • Added clarifying criteria for to allow one modality on a given date of service.
        • Added clarifying language to criteria for diagnostic selective nerve root block at a level other than the initial level.
        • Added clarification transforaminal injections can be “unilateral or bilateral”.
      • CMM 211 Spinal Cord and Dorsal Root Ganglion Stimulation:
        • Editorial/formatting changes for consistency across all guidelines.
        • Updated CRPS section:
          • Updated to require only three categorical symptoms for CRPS versus four (consistent with Budapest Criteria); adding criteria for “absence of other diagnoses concordant with present symptoms”; and limiting coverage “only to extremities”.
        • Updated Chronic Angina section:
          • Updated criteria to optimal pharmacologic treatment (OMT) to include:
            • Antiplatelet therapy.
            • Statins.
            • Anti-anginal therapy.
            • Antihypertensive therapy.
        • Updated Replacement section:
          • Maintained EIU position for painful diabetic peripheral neuropathy.
          • Added as not covered:
            • Chronic spine pain without prior spine surgery.
            • Abdominal pain second to celiac artery compression syndrome.
            • Neuropathic pain associated with multiple sclerosis.

    • Important changes to the joint surgery CMM guidelines posted on April 1, 2022, effective August 1, 2022:
      • CMM 318 Shoulder Arthroplasty:
        • Added “Walch Classification” in definition section:
          • Used to define glenohumeral osteoarthritis and to assist with preoperative planning.
        • Changed Charcot arthropathy to Charcot joint.
        • Other editorial /formatting changes.
        • Added irreparable shoulder fracture as a criteria under “Reverse Total Shoulder Arthroplasty” as well as Glenoid retroversion on imaging using the Walch classification.
      • CMM 315 Shoulder Surgery Arthroscopic and Open:
        • Editorial/formatting changes.
        • Separated criteria for labral and biceps tenodesis into two sections.
      • CMM 314 Hip Surgery Arthroscopic and Open:
        • Editorial/formatting changes.
        • Added parenthetical in non-surgical management “(e.g., steroid, and/or viscosupplementation)”
      • CMM 313 Hip Replacement:
        • Editorial/formatting changes.
        • Added parenthetical in non-surgical management “(e.g., steroid, and/or viscosupplementation)”.
      • CMM 312 Knee Surgery Arthroscopic and Open:
        • Added ACL repair as EIU.
        • Added clarification to medial patellofemoral ligament changes, which will expand coverage, otherwise no major changes.
      • CMM 311 Knee Replacement Arthroplasty:
        • Added parenthetical (e.g., steroid, and/or viscosupplementation) to non-surgical management definition.
        • Added knee varus deformity of “> or = 10 degrees and coronal tibiofemoral subluxation of > or = 6 mm consistent with an ACL deficient osteoarthritic knee” criteria to partial knee.
        • Changed Charcot arthropathy to Charcot joint.
        • In EIU section (modular or monolithic/nonmodular), added to bicompartmental for clarification.
Gastrointestinal Endoscopic Procedures guidelines Modified
  • Important changes posted July 1, 2022, effective October 1, 2022:
    • Editorial and formatting changes to Esophagogastroduodenoscopy (EGD) to improve clarity:
      • Defined and clarified the following terms:
        • Typical gastroesophageal reflux disease (GERD).
        • Persistent vomiting.
        • Dyspepsia.
        • GI bleeding (not hemorrhoidal bleeding).
      • Updated risk factors for Barrett's esophagus.
      • Updated definition of chronic GERD symptoms from > five years, and/or frequent (weekly or more) to weekly symptoms for five or more years.
    • Added informational statement on endoscopic ultrasound and its relation to EGD.
    • Added additional indication for EGD for diagnosis of GERD:
      • An EGD may be done when symptoms return after the discontinuation of an eight week trial of empiric proton pump inhibitors (PPIs) once daily before a meal.
    • Updated the PPI anti-secretory failure requirements:
      • EGD for typical GERD:
        • Removed option of a four-week trial of twice daily PPI therapy.
      • EGD for chest pain attributed to reflux (non-cardiac chest pain, non-typical GERD):
        • Removed requirement for four-week trial of twice daily PPI therapy.
      • EGD for extra-esophageal reflux accompanied by typical GERD symptoms (heartburn, regurgitation):
        • Changed the failure to respond timeframe and dosage from 4-week trial of twice daily PPI OR 8-week trial of once daily PPI therapy to an 8-12 week trial of twice daily PPI therapy.
      • EGD for extra-esophageal reflux not accompanied by typical GERD symptoms:
        • Added new criteria to be met for PPI failure: failure to respond to an 8-12 week trial of twice daily PPI therapy.
    • Updated Barrett’s esophagus (BE) surveillance intervals:
      • If EGD shows no dysplasia on initial screening then repeat EGD intervals are based on the length of Barrett’s epithelium:
        • < 3 cm: repeat in 5 years.
        • ≥ 3 cm: repeat in 3 years.
      • For BE with low grade dysplasia on initial screening when endoscopic surveillance is elected instead of treatment:
        • Repeat EGD at 6 and 12 months and then annually.
      • Follow up surveillance intervals after complete eradication of Barrett’s epithelium for low-grade dysplasia:
        • Repeat EGD at 1 and 3 years then every 2 years thereafter.
      • Follow up surveillance intervals after complete eradication of Barrett’s epithelium for high-grade dysplasia and intramucosal carcinoma.
        • Repeat EGD at 3, 6, and 12 months then annually.
Policies Status Details
Administrative Policies
  • No policy changes for July 2022
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The information in this section is effective July 1, 2022, unless otherwise noted:
Epinephrine Injection (Self-Administered) - (IP0385) New
  • Supports use of:
    • Adrenaclick authorized generic
    • Auvi-Q.
    • EpiPen.
    • EpiPen Jr.
    • Symjepi.
Intraarticular Hyaluronic Acid Derivatives - (IP0322) New
  • Replaces Viscosupplementation for Osteoarthritis – (1405)
  • Supports medical precertification of:
    • Durolane.
    • Euflexxa.
    • Gel-One.
    • Gelsyn-3.
    • GenVisc 850.
    • Hyalgan.
    • Hymovis.
    • Monovisc.
    • Orthovisc.
    • Supartz FX.
    • Synojoynt.
    • Synvisc.
    • Synvisc-One.
    • Triluron.
    • Trivisc.
    • Visco-3.
  • Clarified prerequisite therapy requirements by requiring at least:
    • One course of physical therapy.
    • Two pharmacologic therapies.
    • One course of intraarticular corticosteroids.
  • Modified preferred product requirements.
  • Updated conditions not covered section with addition of two specific indications:
    • Acute ankle sprain.
    • Treatment of joints other than knee.
Tetracycline Antibiotics - (IP0396) New
  • Supports pharmacy prior authorization of:
    • Acticlate.
    • Doryx.
    • Doxycycline DR (doxycycline hyclate 50 mg, 75 mg, 100 mg, 150 mg and 200 mg delayed release tablets).
    • Doxycycline IR (doxycycline monohydrate 40 mg biphasic release capsules).
    • Minolira ER.
    • Monodox.
    • Oracea.
    • Solodyn.
    • Soloxide.
    • TargaDOX.
    • Vibramycin.
    • Ximino ER.
Abrocitinib - (IP0404)

Belimumab Subcutaneous – (IP0430)

Brodalumab - (IP0246)
Guselkumab - (IP0234)
Levoketoconazole - (IP0389)
  • Effective July 15, 2022.

Methotrexate for Injection – (IP0411)
Mupirocin - (IP0390)

Omadacycline - (IP0379)

Sinecatechins - (IP0393)

Tasimelteon – (IP0428)
  • Replaces Tasimelteon – (P0018).

Tizanidine - (IP0392) 		New
  • Supports pharmacy prior authorization requirements.
Belimumab Intravenous – (IP0429) New
  • Supports medical precertification requirements.
Angiotensin Receptor Blockers – (IP0362) Modified
  • Important changes in coverage criteria:
    • Added valsartan 4 mg/mL oral solution.
    • Reformatted to improve clarity.
Antiemetic Therapy - (1705) Modified
  • Important change in coverage criteria, effective July 15, 2022:
    • Added Anzemet with medical necessity exception criteria.
Antihyperglycemic Therapy (Non-Insulin) - (P0098) Modified
  • Minor changes in coverage criteria/policy, effective July 6, 2022:
    • Added Mounjaro (tirzepatide).
      • Mounjaro is a prerequisite option for Adlyxin.
Antimalarial Therapy - (P0101) Modified
  • Minor changes in coverage criteria/policy:
    • Removed Malarone, Plaquenil and Qualaquin.
Azathioprine - (IP0337) Modified
  • Important changes in coverage criteria:
    • Added criteria for azathioprine 75 mg and 100 mg.
    • Modified criteria for Azasan (azathioprine) 75 mg and 100 mg.
Budesonide - (P0084) Modified
  • Minor change in coverage criteria/policy, effective July 15, 2022:
    • Updated preferred product requirement for Ortikos.
Butalbital Combination Products - (IP0025) Modified
  • Minor change in coverage criteria/policy:
    • Added Vtol.
Cabotegravir-Rilpivirine (IP0123) Modified
  • Important changes in coverage criteria:
    • Revised criteria for “Human Immunodeficiency Virus (HIV)-1, Treatment”.
    • Clarified conditions not covered.
Cannabidiol – (IP0410) Modified
  • Important changes in coverage criteria:
    • Revised criteria for Dravet Syndrome and Lennox-Gastaut Syndrome.
Corticosteroid/Long-Acting Beta2-Agonist Combination Inhalers - (IP0022) Modified
  • Important change in coverage criteria:
    • Removed AirDuo Digihaler.
Cysteamine bitartrate delayed-release – (IP0046) Modified
  • Minor change in coverage criteria/policy:
    • Revised genetic testing language.
Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List – (1601) and

Drugs/Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List – (1602)		 Modified
Fenfluramine – (IP0042) Modified
  • Important changes in coverage criteria:
    • Revised criteria for Dravet Syndrome.
    • Added criteria for Lennox-Gastaut Syndrome.
Finerenone - (IP0314) Modified
  • Important changes in coverage criteria:
    • Removed prerequisite requirement for individual to be on a maximally tolerated labeled dosage of an angiotensin converting enzyme (ACE) inhibitor OR angiotensin receptor blocker (ARB).
    • Removed pretreatment baseline levels for:
      • Estimated glomerular filtration rate ≥ 25 mL/min/1.73 m2.
      • Urine albumin-to-creatinine ratio ≥ 30 mg/g.
      • Serum potassium level ≤ 5.0 mEq/L.
    • Removed preferred product prerequisite step through Farxiga.
Immunomodulators - Oral and Subcutaneous (Cigna Total Savings Drug List) - (2102) and

Immunomodulators – Oral and Subcutaneous (Individual and Family Plans) - (1903) and

Immunomodulators – Oral and Subcutaneous (Standard/ Performance, Value/ Advantage, Legacy Drug List Plans) - (1805)		 Modified
  • Important changes in coverage criteria, effective July 15, 2022:
Insulin Glargine – (P0023) Modified
  • Important changes in coverage criteria:
    • Moved Basaglar to nonpreferred brand on Select and Performance benefit plans.
    • Moved SEMGLEE-YFGN to preferred brand on Select and Performance benefit plans.
    • Added Basaglar medical necessity exception criteria for Select and Performance benefit plans.
    • Added Insulin Glargine, Insulin Glargine SoloStar 100 units/mL.
Lonafarnib - (IP0107) Modified
  • Minor changes in coverage criteria/policy:
    • Updated background and references.
      • No changes to criteria intent.
Medication Administration Site of Care - (1605) Modified
  • Minor changes in coverage criteria/policy, effective July 15, 2022:
    • Moved program drug list table to new document:
      • Specialty Care Options and Specialty Care Options Plus - Drug List and Frequently Asked Questions for Health Care Providers.*
Oncology Medications – (1403) Modified
  • Important changes in coverage criteria, effective July 15, 2022:
    • Revised criteria for:
      • Herceptin.
      • Herceptin Hylecta.
      • Herzuma.
      • Ogivri.
      • Ontruzant.
Opioid Therapy - (1704) Modified
  • Important change in coverage criteria:
    • Added Seglentis.
Pharmacy Prior Authorization – (1407) Modified
  • Minor change in coverage criteria/policy:
    • Removed Nuzyra.
Pulmonary Hypertension (PH) Therapy - (6121) Modified
  • Important changes in coverage criteria:
    • Updated prerequisite approach from documented intolerance to new multisource brand language for:
      • Adcirca.
      • Letairis.
      • Revatio (tabs and suspension).
      • Tracleer (62.5 mg and 125 mg).
Rituximab for Non-Oncology Indications – (IP0319) Modified
  • Minor changes in coverage criteria/policy, effective July 15, 2022::
    • Minor correction to antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis.
    • Added a no concomitant use statement to “Conditions Not Covered” section to align with Complement Inhibitors policy – (1103).
Secukinumab - (IP0223) Modified
  • Minor change in coverage criteria/policy:
    • Added Rinvoq (upadacitinib) to ankylosing spondylitis list of covered alternatives.
Step Therapy – Legacy Prescription Drug List (Employer Group Plans) – (1803) and
Step Therapy – Standard and Performance Prescription Drugs Lists (Employer Group Plans) – (1801)		 Modified
  • Important changes in coverage criteria:
    • Added AirDuo Digihaler to step therapy.
    • Revised the “Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers (ACE/ARB)” category.
Step Therapy – Value and Advantage Prescription Drug Lists (Employer Group Plans) – (1802) Modified
  • Important change in coverage criteria:
    • Added AirDuo Digihaler to step therapy.
Upadacitinib - (0229) Modified
  • Important changes in coverage criteria, effective July 15, 2022:
    • Added criteria supporting new ankylosing spondylitis indication.
Voclosporin - (IP0122) Modified
  • Important changes in coverage criteria:
    • Added criterion for biopsy confirmed lupus nephritis (WHO class III, IV, or V).
    • Removed criterion that allows for use not in combination with a background immunosuppressive regimen.
    • Simplified reauthorization criteria without change to intent.
Voretigene Neparvovec - (IP0160) Modified
  • Minor changes in coverage criteria/policy:
    • Updated wording to reflect current genetic terminology.
Belimumab – (1114) Retired
Tasimelteon – (P0018) Retired
Tetracycline Antibiotics - (P0100) Retired
Viscosupplementation for Osteoarthritis - (1405) Retired
Policies Status Details
Cigna National Formaulary (CNF) Coverage Policies
  • Cigna National Formulary (CNF) policies are located on the CNF Policies A-Z Index.
    • Policies are listed alphabetically by document title
      • Document titles include the policy type and may include the drug name, class, and/or condition
    • Policies can also be searched by a product identification (ID) number, which is a unique identifier to a specific product/policy.
      • When applicable, searching by product ID helps locate the corresponding CNF policy.
    • Details of updates to each CNF policy are located under the “Revision History” section.
  • More information about Cigna's drug lists can be found at Prescription Drug Lists and Coverage | Cigna
  • More information about Cigna's drug lists changes can be found at CHCP - Resources - Cigna's Prescription Drug Lists.
    • CNF formulary changes can be found in the Prescription Drug List Changes document under Cigna National Prescription Drug List, located at the bottom of the page.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for July 2022
Policies Status Details
Precertification List – Commercial (Non-Medicare) Business
  • No updates for July 2022
Policies Status Details
Precertification List – Medicare Business
Master Precertification List
  • See information in the eviCore section for important changes, effective July 29, 2022.
Policies Status Details
Reimbursement Policies*
COVID-19 Interim Billing Guidelines – (R33)

Healthcare Common Procedure Coding System (HCPCS) National Level II Modifiers – (MHCPCS)

Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service - (M25)

Modifier Reference Guide – (MRG)

Omnibus Reimbursement Policy - (R24)

Virtual Care – (R31) 		Modified
  • Policies were updated.
Policies Status Details
ClaimsXten*
Code Editing Policy and Guidelines Modified
  • Important changes effective August 13, 2022:
    • Updated to Third Quarter Knowledge Base content and NCCI Version 28.2 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] 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.