Policy Updates June 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 of Arrhythmogenic Foci in the Pulmonary Veins for the Treatment of Atrial Fibrillation - (0469)

  • We will update our medical coverage policy and implement a precertification requirement for CPT codes 93656 and 93657 to review this procedure for medical necessity.
  • This update is effective for dates of service on or after June 15, 2018.

Cervical Fusion - (0527) (new)

  • We will implement a new medical coverage policy and require precertification for Anterior Cervical Discectomy (ACDF) and Posterior (Cervical) Spinal Fusion (PSF) procedures billed with CPT codes 22551, 22554, and 22600.
  • This update is effective for dates of service on or after June 22, 2018.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective June 15, 2018:
Cervical Fusion – (0527) New
  • Advance notification originally provided on March 15, 2018, with effective date of June 15, 2018..
    • Supports anterior and posterior cervical fusion.
    • Implemented through precertification.
  • Cervical fusion medical necessity criteria addresses:
    • single/multilevel degenerative disease,
    • conditions resulting in cervical spinal instability,
    • iatrogenic instability,
    • instability resulting from spinal stenosis with spondylolisthesis,
    • instability of adjacent or same level instability resulting from prior spine surgery without a spondylolisthesis,
    • pseudoarthrosis following a prior spinal surgery.
  • Cervical fusion considered not medically necessary:
    • with initial primary laminectomy/discectomy for nerve root decompression or spinal stenosis in the absence of spondylolisthesis or kyphosis,
    • for treatment of spinal stenosis in the absence of spondylolisthesis or spinal instability,
    • for chronic axial neck pain,
    • for posterior cervical fusion performed with laminectomy in the absence of kyphosis (e.g., degenerative spine) or subluxation/translation of more than 3.5 mm.
Breast Pumps – (0046) Modified
  • Important change in coverage criteria:
    • Added new not covered policy statement for wireless breast pump.
      • No change in coverage.

Donor Lymphocyte Infusion and Hematopoietic Progenitor Cell (HPC) Boost – (0261)

Modified
  • Important change in coverage criteria:
    • Added covered policy statement of hematopoietic Progenitor Cell (HPC) Boost.
    • Title updated from “Donor Lymphocyte Infusion.”
Infertility Services - (0089) Modified
  • Important change in coverage criteria:
    • Added vaginal microbiome to existing not covered policy statement.
Obstructive Sleep Apnea Diagnosis and Treatment Services - (0158) Modified
  • Important changes in coverage criteria:
    • Added verbiage to align with standard of care and American Academy of Sleep Medicine guidelines/statement.
Omnibus Codes - (0504) Modified
  • Important changes in coverage criteria:
    • Updated gastroenterology section:
      • Removed Elastography
      • Removed Transanal Endoscopic Microsurgical (TEMS) Approach for Excision of Rectal Tumor.
      • Added 13C-Spirulina Gastric Emptying Breath Test (GEBT) as not covered:
        • Considered experimental, investigational, unproven (EIU).
        • No change in coverage.
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty - (0040) Modified
  • Advanced notification of important change in coverage criteria effective September 15, 2018:
    • Added imaging requirement.
Rhinoplasty, Vestibular Stenosis Repair and Septoplasty - (0119) Modified
  • Important change in coverage criteria:
    • Added new not covered policy statement for Latera Absorbable nasal implant:
      • No change in coverage.
Sleep Testing Services – (0524) Modified
  • Important changes in coverage criteria:
    • Added verbiage to align with standard of care and American Academy of Sleep Medicine Guidelines/Statements.
    • Added SomnaPatch device to existing not covered policy statement.
Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins for the Treatment of Atrial Fibrillation - (0469) Modified
  • Advance notification of important changes in coverage criteria originally provided on March 10, 2018M for changes effective June 15, 2018:
    • Added criteria defining symptomatic and antiarrhythmic medication use.
      • Added applicable codes to precert.
Tumor Profiling, Gene Expression Assays, and Molecular Diagnostic Testing for Hematology/Oncology Indications - (0520) Modified
  • Important changes in coverage criteria:
    • Removed non-Hodgkin lymphoma from the indications for which tumor analysis/gene expression profiling is not covered.
    • Added covered policy statement for Tumor Tissue-Based Molecular Assays for Prostate Cancer.
Ultrasound in Pregnancy (Including 3D and 4D Ultrasound) - (0142) Modified
  • Advance notification of important changes in coverage criteria originally provided on March 10, 2018M for changes effective June 15, 2018:
    • Increased number of allowed ultrasounds from one to ≤ two standard or limited ultrasounds per routine pregnancy.
    • Added coverage for a specialized ultrasound, only if billed with an abnormality/complication diagnosis code.
Vitamin D Testing - (0526) Modified
  • Important changes in coverage criteria:
    • Added new code 0038U:
      • Same procedure-to-diagnosis (PXDX) codes as 82306.
      • No change in coverage.
Complex Lymphedema Therapy (Complete Decongestive Therapy) – (0076) Retired
Sensory and Auditory Integration Therapy-Facilitated Communication – (0283) Retired
  • Replaced with new Cigna-ASH cobranded CPG Sensory and Auditory Integration Therapy-Facilitated Communication – (CPG 149).
Strapping and Taping – (0512) 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 June 15, 2018:
Complex Lymphedema Therapy (Complete Decongestive Therapy (CPG 157) New
  • Clarified intent.
  • No change in coverage.
  • Retired medical coverage policy Complex Lymphedema Therapy (Complete Decongestive Therapy) – (0076)
Manual Muscle Testing and Range of Motion Testing - (CPG 146) New
  • Does not replace an existing Cigna medical coverage policy.
Sensory and Auditory Integration Therapy-Facilitated Communication (CPG 0149) New
  • Clarified intent.
  • No change in coverage.
  • Retired medical coverage policy Sensory and Auditory Integration Therapy-Facilitated Communication – (0283)
Strapping and Taping - (CPG 143) New
  • Clarified intent.
  • No change in coverage.
  • Retired medical coverage policy Strapping and Taping – (0152).
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Policies Status Details
Administrative Policies
Midwife, Home Birth and Nonclinical Maternal Services – (A002) Modified
  • Changed title from “Home Birth”.
  • Added information to expand scope and include services provided by midwives with no change to intent of coverage.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective June 15, 2018:
Carbidopa and levodopa enteral suspension - (1606) Modified
  • Important changes in coverage criteria:
    • Defined “Off” time in first bullet.
    • Removed “History of” from second bullet.
Quantity Limitations – (1201) Modified
  • Important changes in coverage criteria:
    • Added quantity limit of one tablet per day for Zocor (simvastatin).
    • Removed discontinued products:
      • Sotret
      • Alsuma
    • Moved quantity limits from interim criteria for Ozempic and Daliresp 250mg.
    • Added quantity limits for PPIs, Antidepressants, and Safety Drugs.
    • Added quantity limit for generic Treximet (Sumatriptan/Naproxen).
Step Therapy – (1109) Modified
  • Important change in coverage criteria:
    • Added Zypitamag to Step 3 Medication in the Statin Class.
Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803) Modified
  • Important changes in coverage criteria:
    • Corrected Statin Step Therapy to reflect requiring Two Step 1 Agents before a Step 3 Medication for the Complete and Essential Plan.
    • Added Zypitamag as a Step 3 Medication in the Statin Class.
Step Therapy - Standard Prescription Drug Lists (Employer Group Plans) - (1801) Modified
  • Important change in coverage criteria:
    • Corrected Statin Step Therapy to reflect requiring two Step 1 agents before a Step 3 medication for the Complete and Essential Plan.
Viscosupplementation for Osteoarthritis - (1405) Modified
  • Important changes in coverage criteria:
    • Added Durolane and Visco-3 as nonpreferred brands.
    • Expanded the diagnosis criteria statement.
    • Updated the contraindication/intolerance to preferred products statement:
      • Provides greater clarity of intent.
      • No change to criteria intent.
    • Moved EIU indications from background to EIU criteria statement and updated the statement to the current standard.
    • Added the following to EIU statement:
      • The combination of any other product, (for example platelet rich plasma (PRP), stem cell products, amniotic products, corticosteroids) with a viscosupplement injection.
The following pharmacy (drugs & biologics) coverage policies were modified effective July 1, 2018:
Dupilumab – (1810) New
  • Note - link will not be active until June 30, 2018.
  • Supports pharmacy prior authorization.
Controlled Substance Analgesic and Narcotic Antagonist Quantity Limitations - (1706) Modified
  • Important changes in coverage criteria:
    • Removed Arymo ER and Morphabond ER from the Long-Acting Opioid section.
    • Removed the Short-Acting Opioids and Cough Combination sections.
    • Removed quantity limits from the Headache Combinations section for:
      • Codeine-butalbital-caffeine-APAP tablet,
      • Codeine-butalbital-caffeine-APAP capsule,
      • Codeine-butalbital-caffeine-aspirin capsule.
    • Updated the Buprenorphine (Belbuca) buccal film quantity limit to two films per day in the Pain Control section.
    • Removed Pentazocine-acetaminophen tablet and Pentazocine-naloxone tablet quantity limits from the Pain Control section.
Denosumab - (1212) Modified
  • Important changes in coverage criteria:
    • Added step language to prefer zoledronic acid over Xgeva.
    • Added “history of beneficial clinical response” language to Prolia and Xgeva products.
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
  • Important changes in coverage criteria:
    • Removed Victoza criteria.
    • Added criteria for:
      • Steglatro
      • Steglujan
      • Segluromet
      • Mycobutin
      • Solaraze
      • Diclofenac 3%
      • Auvi Q 0.1mg/0.1ml
    • Removed age bullet from Luzu criteria.
    • Updated Adlyxin and Tanzeum criteria, corrected spelling errors for Rowasa.
    • Added link to Multiple Sclerosis Therapy - (1402) for Copaxone.
    • Removed Dextroamphetamine ER (generic for Dexedrine) bullet for Mydayis.
Lysosomal Storage Disorders – (1319) Modified
  • Important change in coverage criteria:
    • Added criteria to require Cerdelga before Zavesca in new starts for individual with Gaucher’s disease, including language for history of beneficial clinical response to Zavesca.
Multiple Sclerosis Therapy - (1402) Modified
  • Important changes in coverage criteria:
    • Removed Copaxone as a preferred product.
    • Added Glatiramer acetate as a preferred product.
    • Added medical necessity criteria requiring documented intolerance to the generic and documented failure, contraindication per FDA label, intolerance, or not a candidate for one preferred product, before Copaxone.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Added to pharmacy benefit table:
      • Hycamtin
      • Targretin®
      • Vesanoid
      • Xeloda®
    • Added step therapy language for:
      • Fusilev®
      • Targretin
      • Temodar
      • Xeloda
Opioid Therapy - (1704) Modified
  • Important changes in coverage criteria:
    • Decreased immediate-release opioid day supply limit from 15 to 7 days for opioid naïve individuals.
    • Modified immediate-release opioid criteria to include requirements specific to acute vs. chronic pain.
    • Added criteria for transdermal fentanyl and methadone to support pharmacy prior authorization.
    • Removed step therapy requirements for non-preferred or non-formulary products for end-of-life care.
    • Added criteria to support medical necessity review when the total opioid daily dose exceeds 120 (increased from 50) and 200 morphine milligram equivalents.
Pharmacy Prior Authorization - (1407) Modified
  • Important change in coverage criteria:
    • Added criteria for Nityr and Orfadin®.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for June 2018.
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
  • No updates for June 2018.

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.