Policy Updates June 2016

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective June15, 2016:
Airway Clearance Devices in the Ambulatory Setting - (0069) Modified
  • Important change in coverage:
    • Added policy statement for coverage of new airway clearance device system.
Breast Pumps - (0046) Modified
  • Important change in coverage:
    • Updated existing policy statement allowing for exception to requirement that standard electric breast pump has been tried and failed when the baby is in neonatal intensive care unit (NICU).
Infertility Services - (0089) Modified
  • Important change in coverage:
    • Added policy statement for coverage of mature oocytes during active IVF cycles when there are no viable sperm at time of retrieval.
  • Policy statement updates with no change in coverage:
    • Updated definitions of infertility to include reference to same sex couples.
    • Removed insemination from list of female infertility treatments.
    • Added T1:T2 Helper cells and uterine transplantation as experimental, investigational or unproven (EIU).
Inhaled Nitric Oxide (INO) - (0453) Modified
  • Important change in coverage:
    • Added policy statement for coverage of postoperative management of pulmonary hypertensive crisis following pediatric heart or lung surgery.
Intervertebral Disc (IVD) Prosthesis - (0104) Modified
  • Important change in coverage:
    • Added policy statement for coverage of cervical IVD prosthesis at two contiguous levels.
Minimally Invasive Intradiscal/Annular Procedures and Trigger Point Injections - (0139) Modified
  • Policy statement update with no change in coverage:
    • Added endoscopic cervical laser disc decompression (Cervical Deuk Laser Disc Repair®) as EIU.
    • Changed ultrasound guidance for trigger points from not medically necessary (NMN) to EIU.
Pneumatic Compression Devices and Compression Garments - (0354) Modified
  • Important change in coverage:
    • Removed not covered policy statement for advanced pneumatic pump.
      • Now covered the same as other segmented, calibrated gradient systems included in HCPCS code E0652.
Circulating Tumor Cell Testing - (0262) Retired
The following two coverage policies have also been retired: Retired
  • Maze Procedure - (0054)
  • Thermography/Temperature Gradient Studies - (0065)
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective June 15, 2016:
Carbidopa and Levodopa (Duopa) Enteral Suspension - (1606) New
  • Supports medical precertification.
Insulin Recombinant Human (Afrezza®) - (1506) Modified
  • Important changes in coverage:
    • Removed criteria of "inadequate response to preferred short acting insulin."
    • Changed wording and provided examples for unable to administer.
    • Modified criteria for oral antihyperglycemics for individuals with type 2 diabetes mellitus to be more specific.
Oral Phosphodiesterase-5 (PDE5) Inhibitors - (7003) Modified
  • Important changes in coverage:
    • Removed brand names from sildenafil and tadalafil for use of PDE5-inhibitors for Raynaud's disease.
    • Clarified approval duration of Cialis when used for benign prostatic hyperplasia (BPH).
Quantity Limitations - (1201) Modified
  • Important changes in coverage:
    • Added OnzetraTM XsailTM to antimigraine list.
    • Modified Onmel quantity limit in the anti-infective list to correlate to package size available.
Somatropin (Genotropin®, Humatrope®, Norditropin®, FlexPro®, Nutropin®, Nutropin ®AQ, Omnitrope®, Saizen®, Serostim®, Zomacton, Zorbtive®) - (4012) Modified
  • Important update:
    • Added Serostim® as a preferred product.
      • No change to coverage criteria.
Step Therapy - (1109) Modified
  • Important changes in coverage:
    • Added Rosuvastatin to Statin Step 1.
    • Moved Crestor from Statin Step 2 to Statin Step 3.
    • Removed Mevacor from Statin Step 3 due to product unavailability.
    • Removed Liptruzet™ from Statin Step 3 due to product unavailability.
    • Removed acute oral narcotics and added long-acting oral narcotics.
    • Removed long-acting narcotic list from Emerging Step Therapy and added to Global Step Therapy.
    • Removed asthma nebulizer solutions and added chronic obstructive pulmonary disease (COPD).
    • Removed COPD medication list from Emerging Step Therapy and added to Global Step Therapy.
    • Moved Nasonex from Step 2 Nasal Steroid to Step 3.
    • Added "/Trintellix" to Brintellix in Antidepressant list due to name change with FDA.
    • Added Flurandrenolide to Step 1 Topical Immunomodulators.
    • Removed Ultravate PAC from Step 3 Topical Immunomodulators due to product unavailability.
Step Therapy Individual and Family Plans - (1603) Modified
  • Important changes in coverage:
    • Added Rosuvastatin to Statin therapy, Step 1.
Viscosupplementation for Osteoarthritis - (1405) Modified
  • Important changes in coverage:
    • Added "not a candidate for" language for prior therapies to account for warnings/precautions, drug-drug interactions, etc. with other treatment options for osteoarthritis.
    • Removed "non-narcotic" to accept narcotic and non-narcotic analgesics.
Policies Status Details
Administrative Policies
Unless otherwise noted, the following medical coverage policies were modified effective June15, 2016:
Preventive Care Services - (A0004) New
  • This is a new administrative policy.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Seventeen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
Policies Status Details
Reimbursement Policies*
No updates for June 2016.
Policies Status Details
Claim Editing Policies and Procedures ClaimsXten
No updates for June 2016.
Policies Status Details
Policies with a Reduction in Coverage**
There were no additional policy updates that resulted in a reduction of coverage.

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.

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