Policy Updates June 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
There were no additional changes made in June 2019 that resulted in a reduction in coverage.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective June 15, 2019:
Emerging Surgical Procedures for Glaucoma - (0035) Modified
  • Important changes in coverage criteria:
    • Added new policy statement for coverage of canaloplasty.
    • Added experimental, investigational or unproven (EIU) policy statement for:
      • gonioscopy-assisted transluminal trabeculotomy (GATT)
      • ab internal intracanalicular scaffold (i.e., Hydrus Microstent).
      • ab interno trabecular micro-bypass system with two stents (i.e., iStent iject).
Infertility Services - (0089) Modified
  • Important change in coverage criteria:
    • Added “sono-air hysterosalpingogram” to existing EIU policy statement.
Obstructive Sleep Apnea Diagnosis and Treatment Services - (0158) Modified
  • Important change in coverage criteria:
    • Added policy statement addressing positive airway pressure (PAP) cleaning machines as a convenience item and not medically necessary.

Omnibus Codes - (0504)

Modified
  • Minor changes in coverage criteria/policy:
    • Moved benefit disclaimer from Oxygen for Home Use – (0207) into this policy.
      • Retiring Oxygen for Home Use – (0207).
Rhinoplasty, Vestibular Stenosis Repair and Septoplasty - (0119) Modified
  • Minor changes in coverage criteria/policy:
    • Removed HCPCS code C9749 from policy statement on repair of nasal valve collapse with absorbable nasal implant.
Sleep Testing Services – (0524) Modified
  • Important changes in coverage criteria:
    • Multiple policy statement updates based on evaluation of current coverage policy against the American Academy of Sleep Medicine (AASM) Guideline scorecard for Diagnostic Testing.
      • The scorecard has nine criteria that correspond to the clinical practice recommendations in the AASM guideline on the diagnostic testing for obstructive sleep apnea (OSA).
    • Updated policy statement aligning comorbid conditions across in-facility sleep testing.
    • Added additional criteria for multiple sleep latency testing (MSLT).
Umbilical Cord Blood Banking - (0466) Modified
  • Minor change in coverage criteria/policy:
    • Removed policy statement:
      • Unnecessary because infant is covered under the mother for first 30 days (or as a donor if not a Cigna customer, same as any other live donor).
Oxygen for Home Use – (0207) Retired
Prothrombin Time Home Testing Systems – (0109) Retired
  • Retired on June 1, 2019.
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • No new or updated policies for June 2019.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Originally provided advance notification on April 1, 2019, of updates to the following Cigna-eviCore Cobranded Radiation Therapy guideline, effective July 1, 2019: Modified
  • Proton Beam Therapy
    • Divided the coverage policy statement into three groups:
      • Covered
      • Not medically Necessary (NMN)
      • EIU
    • Added coverage for intrahepatic cholangiocarcinoma and craniospinal irradiation.
    • Added eight new indications to the not medically necessary list of conditions:
      • Primary central nervous system (CNS) cancer.
      • Remaining cases of unresectable hepatocellular carcinoma and intrahepatic cholangiocarcinoma.
      • Hodgkin’s lymphoma.
      • Non-Hodgkin's lymphoma.
      • Stage IIIB non-small cell lung cancer.
      • Pancreatic cancer.
      • Retroperitoneal sarcoma.
      • Thymomas and thymic carcinoma.
    • Combination of photon and proton delivered in a stereotactic manner changed from EIU to covered.
    • Proton Beam delivered in a stereotactic manner changed from EIU to covered.
  • Radiation Therapy for Prostate Cancer
    • Removed coverage statement for stereotactic body radiation therapy (SBRT) for high risk prostate cancer based on recently published American Society of Clinical Oncology (ASCO) guideline and policy.
  • Radiation Treatment with Lutathera (Lutetium; Lu 177 dotatate)
    • Added coverage for inoperable or metastatic somatostatin receptor positive bronchopulmonary thymic tumors in adults based on National Comprehensive Cancer Network (NCCN) and the evidence.
  • Selective Internal Radiation Therapy
    • Added coverage for “Unresectable metastatic liver tumors from other primary malignancies, including breast carcinoma, ocular melanoma, cutaneous melanoma, and intrahepatic cholangiocarcinoma, in the absence of available systemic or liver-directed treatment options for relief of symptoms” based on NCCN guideline and literature.
  • Policies Status Details
    Administrative Policies
    • No updates for June 2019.
    Policies Status Details
    Pharmacy (Drugs & Biologics) Policies
    Unless otherwise noted, the following medical coverage policies were modified effective June 1, 2019:
    Esketamine – (M0010) New
    • Supports medical precertification of Spravato (esketamine).
    Canakinumab – (1110) Modified
    • Minor changes in coverage criteria/policy:
      • Removed requirement of diagnosis confirmed according to known genetic MVK/enzymatic (MKD) for hyper-IgD due to approximately one-quarter of patients with compatible clinical symptoms, physical findings, and immunoglobulin levels do not have MVK mutations and are categorized as having variant Hyperimmunoglobulin D (Hyper-IgD) syndromes.
      • Added reauthorization criteria that individual must meet initial use criteria and must have disease stability or disease improvement.
    Compounded Medications – (1406) Modified
    • Important changes in coverage criteria:
      • Removed exclusionary criteria for bulk powders.
      • Removed exclusionary statement for pharmacy benefits.
      • Strengthened requirements to “all” commercially products to be used first.
      • Clarified EIU section by removing redundancy and the associated approval criteria.
    Cystic Fibrosis Transmembrane Conductance (CFTR) Modulator - (1207) Modified
    • Minor changes in coverage criteria/policy:
      • Expanded Kalydeco (ivacaftor) age to include six months and older:
        • Recent FDA approval for this range.
    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
    Eteplirsen - (1702) Modified
    • Minor changes in coverage criteria/policy:
      • Simplified ambulation initial criteria statement.
      • Simplified reauthorization criteria.
      • Added reauthorization interval of 12 months.
    Immunomodulators – Oral and Subcutaneous (Employer Group Benefit Plans) – (1805) Modified
    • Important changes in coverage criteria:
      • Added nonradiographic axial spondyloarthritis to be included as part of ankylosing spondylitis criteria:
      • Added Skyrizi (risankizumab-rzaa) to preferred product list for plaque psoriasis:
        • Applicable medical necessity criteria apply.
      • Removed step therapy requirement for Tremfya (guselkumab) for plaque psoriasis.
      • Rearranged preferred products listings when step therapy applies (plaque psoriasis, Polyarticular Juvenile Idiopathic Arthritis, psoriatic arthritis) for clarity.
    Immunomodulators (Individual and Family Plans) – (1903) Modified
    • Minor changes in coverage criteria/policy:
      • Added Skyrizi (risankizumab-rzaa) to preferred product list for plaque psoriasis:
        • Applicable medical necessity criteria apply.
    Mecasermin - (6107) Modified
    • Minor changes in coverage criteria/policy:
      • Clarified “no concurrent treatment for GHD” to specify treatment is growth hormone.
      • Modified note regarding insulin-like growth factor deficiency mutations to closer align with FDA label.
      • Deleted “Yearly reassessment for re-auth of coverage is required” bullet.
    Medication Administration Site of Care - (1605) Modified
    • Minor changes in coverage criteria/policy:
      • Added J0202 alemtuzumab, 1 mg to medical precertification table.
    Oncology Medications - (1403) Modified
    • Minor changes in coverage criteria/policy:
      • Added Balversa (erdafitinib) and Jakafi (ruxolitinib) to pharmacy benefit table.
      • Added Lartruvo (olaratumab) removal from market details to stem and background.
      • Added specific additional criteria for brand-name Tarceva requiring use of the covered alternative, (generic) erlotinib.
    Oxazolidinone Antibiotics - (1123) Modified
    • Important changes in coverage criteria:
      • Added statement clarifying policy addresses the use of oral linezolid and tedizolid, and that IV formulations are not addressed.
      • Simplified Zyvox criteria for all uses relating to:
        • Staphylococcus infections
        • Multi-drug resistant Streptococcal infections
        • Multi-drug resistant tuberculosis
        • Nontuberculous atypical mycobacterial infections
        • No change to current intent of language.
      • Removed age requirement from Sivextro specific coverage criteria responsive to subject matter expert recommendation.
      • Added a continuation of IV therapy criterion to Sivextro specific coverage criteria:
        • No precertification required for IV with coverage under medical.
      • Added authorization statement:
        • No change to how policy is currently implemented.
      • Added treatment of gram-negative infections to EIU statement.
    PCSK9 Inhibitors - (1509) Modified
    • Minor changes in coverage criteria/policy:
      • Added note to specify which Repatha products are covered when criteria are met.
    Pegfilgrastim - (1320) Modified
    • Minor changes in coverage criteria/policy:
      • Added Udenyca to policy responsive to business decision to cover pegfilgrastim-cbqv at parity with Neulasta (pegfilgrastim) and Fulphila (pegfilgrastim-jmdb).
      • Added Individual and Family Plan (IFP) specific benefit language with a step therapy requirement for Neulasta first due to nonformulary status for both Fulphila and Udenyca.
    Protein C Concentrate - (1604) Modified
    • Minor changes in coverage criteria/policy:
      • Revised protein C activity and antigen testing criteria to clarify expected results.
      • Added reauthorization language statement to clarify continuation of use is contingent on initial authorization criteria continuing to be met:
        • No change to how policy is currently implemented.
      • Added initial authorization and reauthorization intervals:
        • No change to how policy is currently implemented.
    Unassigned Drug or Biologic Code Medical Precertification - (1701) Modified
    • Minor changes in coverage criteria/policy:
      • Added Macrilen (macimorelin) criteria.
    Ruxolitinib - (1211) Retired
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    • No updates for June 2019.
    Policies Status Details
    Precertification Policies*
    Policies Status Details
    Reimbursement Policies*
    • No updates for June 2019.
    Policies Status Details
    ClaimsXten*
    • No updates for June 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] 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.