Policy Updates June 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:
Care Integration Services Reimbursement Policy - (R32)
  • We will deny prolonged services as being not separately reimbursable when billed alone or with other services.
  • The affected Current Procedural Terminology (CPT®) codes are 99358 and 99359.
  • This update is effective for claims processed on or after June 15, 2020.
Endometrial Ablation - (0013)
  • We will deny claims submitted with CPT codes 58353, 58356, and 58563 for endometrial ablation when billed with certain diagnoses as being considered experimental, investigational, or unproven (EIU).
  • This update is effective for dates of service beginning June 15, 2020.
Transthoracic Echocardiography in Adults - (0510)
  • We will limit coverage for transthoracic echocardiograms in adults to twice per a rolling 12-month period for certain diagnoses. The frequency limit is based on medical necessity.
  • This update is effective for claims processed on or after June 15, 2020.
Policies Status Details
MCG
  • MCG Cite Guideline Transparency:
    • The Connecticut Department of Insurance requires access to guidelines used for clinical decision making for current and potential Connecticut customers.
    • Although our coverage policies are publicly available, MCG guidelines have previously been provided only upon request.
    • A new link, Cigna Connecticut Guidelines , has been added to the Supporting Websites section of the Cignaforhcp website.
    • This link provides access to the criteria section of MCG guidelines:
      • Inpatient and Surgical Care
      • Ambulatory Care
      • Recovery Facility Care
      • Home Care
    • Utilization management denial letters for Connecticut customers will now reference this link and provide access instructions.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective June 15, 2020:
Cervical Fusion - (0527) Modified
Endometrial Ablation - (0013) Modified
  • Originally provided advance notification on March 15, 2020 of important changes in coverage criteria, effective June 15, 2020:
    • Implementing policy via reverse procedure-to-diagnosis (PXDX) edit.
      • No changes to existing policy statement.
Hearing Aids - (0093) Modified
  • Minor changes in coverage criteria/policy:
    • Updated with no change to coverage.
    • Updated available devices, including the new Osia and Osia 2 Systems:
      • Both are FDA equivalent to bone-anchored devices currently covered.
      • Osia systems provide bone conduction via a piezoelectric method.
Home Ventilators - (0546) Modified
  • Important changes in coverage criteria:
    • Removed bullets requiring affirmative statement that home environment is safe.
Obstructive Sleep Apnea Treatment Services - (0158) Modified
  • Important change in coverage criteria:
    • Changed implanted hypoglossal nerve stimulation device from not covered to covered for a subset of individuals.
    • Multiple edits to criteria and updated additional policy statements to clarify intent of coverage or noncoverage.
Redundant Skin Surgery - (0470) Modified
Rhinoplasty, Vestibular Stenosis Repair and Septoplasty - (0119) Modified
  • Important change in coverage criteria:
    • Added radiofrequency of nasal valve for treatment of nasal airway obstruction (e.g., Vivaer ARC Stylus) to existing experimental, investigation or unproven (EIU) policy statement.
Sleep Testing Services - (0524) Modified
  • Important changes in coverage criteria:
    • Added pre- and post-implantation criteria for implanted hypoglossal nerve stimulation device.
    • Multiple edits to criteria and updated additional policy statements to clarify intent of coverage or noncoverage.
Transthoracic Echocardiography in Adults - (0510) Modified
  • Originally provide advance notification of important changes in coverage criteria on March 15, 2020, effective June 15, 2020:
    • Replaced primary source of policy─the American College of Cardiology (ACC) 2011 Appropriate Use Criteria (AUC) for Echocardiography─with three newer AUCs:
      • 2019 ACC AUC for “Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease”:
        • 103 separate transthoracic echocardiography (TTE) indications.
      • 2017 ACC AUC for “Multimodality Imaging in Valvular Heart Disease (VHD)”:
        • Currently in background only.
        • 92 separate TTE indications.
      • 2020 ACC AUC for “Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease (CHD)”:
        • 324 separate TTE indications.
      • Generally, the newer AUCs replace and greatly expand upon existing 2011 TTE indications.
      • Newer AUCs are driving significant policy reformatting.
    • Added new policy statement to approve myocardial strain imaging before, during, or following exposure to medications/radiation that could result in cardiotoxicity.
      • New January 2020 CPT add-on code 93356.
    • Added new policy statement addressing frequency of TTE:
      • More than two TTEs within a rolling twelve months is considered not medically necessary (NMN).
      • Some diagnoses are exceptions and frequency edit will not apply (e.g., certain malignancy diagnoses).
      • Frequency edit does not apply to individuals under the age of 18.
    • Added new policy statement noting TTE as a screening study before starting attention-deficit/hyperactivity disorder (ADHD) drugs is considered NMN.
  • Advance notification of important changes in coverage criteria, effective August 15, 2020:
    • Added policy statement addressing pre-operative TTE before noncardiac solid organ transplantation.
    • Updated transplant-related ICD10 coding.
Transthoracic Echocardiography in Children – (0523) Modified
  • Originally provided advance notification of important changes in coverage criteria on, March 15, 2020, effective , June 15, 2020, :
    • Keeping primary source─ACC/American Academy of Pediatrics/American Heart Association (ACC/AAP/AHA) 2014 AUC─for initial TTE in outpatient pediatric cardiology:
      • Addresses initial use of outpatient TTE during pediatric (≤18 years of age) outpatient care.
    • Added new source 2020 ACC AUC for “Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease (CHD)”:
      • 324 separate TTE indications.
      • Addresses cardiac imaging in pediatric patients with established CHD.
    • Added new policy statement to approve myocardial strain imaging before, during, or following exposure to medications/radiation that could result in cardiotoxicity.
      • New January 2020 CPT add-on code 93356.
    • Added new policy statement noting TTE as a screening study before starting ADHD drugs is considered NMN.
Treatment of Gender Dysphoria - (0266) Modified
  • Important changes in coverage criteria:
    • Expanded list of procedures considered NMN by standard benefit plans to include lip filling and lip lift.
    • Moved voice modification surgery from NMN/cosmetic section to EIU section.
    • Removed abdominoplasty and calf implants:
      • Not in scope.
    • Added clarification for forehead “reduction/contouring” and put on separate line.
    • Added clarity to procedures NMN to now read “generally not medically necessary”.
    • Added breast reduction and CPT code 19318 to initial mastectomy section in covered table for female to male.
    • Added note clarifying nipple/areola reconstruction is included in CPT code 19318 and not separately payable.
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Sensory and Auditory Integration Therapy - Facilitated Communication – (CPG149) Modified
  • Updated with no change in coverage.
Range of Motion Testing – (CPG146) Modified
  • Important changes in coverage criteria:
    • Updated title from “Manual Muscle Testing and Range of Motion Testing”.
    • Removed manual muscle testing information.
      • Codes deleted effective December 31, 2019; therefore, information no longer needed in policy.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Adult and Pediatric Oncology Imaging guidelines Modified
  • Advance notification of change, posted May 22, 2020, effective August 21, 2020:
    • Updated definition of surveillance.
Policies Status Details
Administrative Policies
Preventive Care Services - (A004) Modified
  • Important changes, effective June 1, 2020:
    • Chlamydia, Gonorrhea, Human Papillomavirus (HPV) Screenings:
      • Added CPT codes 87800 and 87801.
    • Human Immunodeficiency Virus (HIV) Infection Screening:
      • Added CPT codes 80081, 86702, 87534, 87535, 87536 and 87806.
    • Women’s Contraceptive Services: Injection:
      • Added ICD-10 code Z30.013 to Code Group 4
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective June 1, 2020:
Testosterone Therapy (Oral, Nasal, and Topical) – (2013) New
  • Effective June 15, 2020:
    • Removed oral, topical, and nasal products from Testosterone Therapy (Injectables and Implantable Pellets) – (1503) and incorporated them into this new policy.
    • Added hyperlink to retitled Testosterone Therapy (Injectables and Implantable Pellets) – (1503).
    • Added clarification of assay type (equilibrium dialysis only) acceptable for free testosterone level:
      • In response to significant inconsistencies among various labs/assays used for free testosterone, which may lead to inappropriate approvals.
      • Equilibrium dialysis is the current gold standard defined in guidelines.
    • Added “No concurrent use of other testosterone products” statement based on subject matter expert feedback to avoid potential overutilization and safety concerns.
    • Changed the number of preferred formulary alternatives for criteria on Fortesta, Natesto, Testim, Vogelxo, and Jatenzo to three alternatives.
      • Prior list of preferred product alternatives was expanded to list all formulary preferred testosterone gel products.
      • Previously was just listed as “testosterone gel”.
    • Added EIU use “To enhance athletic performance or increase muscle mass”
Supports pharmacy prior authorization requirements. New
Supports medical precertification requirements. New
Supports pharmacy medical necessity coverage. New
Clobazam Oral Film - (P0085) Modified
  • Important changes in coverage criteria:
    • Restricted coverage in Lennox-Gastaut syndrome, to adjunctive and second-line treatment (guideline recommended):
      • Changed required prerequisite alternatives from two forms of clobazam (tablets and suspension) to two antiepileptic drugs and requiring Sympazan to be used with at least one other antiepileptic drug.
    • Expanded coverage to include the adjunctive, second-line treatment of treatment-resistant epilepsy (guideline recommended).
    • Added specialist prescribing requirement for all covered indications.
Clotting Factors and Antithrombin – (8007) Modified
  • Important changes in coverage criteria:
    • Removed three medications due to product discontinuation:
      • Bebulin.
      • Helixate FS.
      • Monoclate-P.
    • Expanded coverage criteria to include for perioperative management of bleeding consistent with FDA label:
      • Alprolix.
      • BeneFIX.
      • Ixinity.
      • Rixubis.
    • Updated Coagadex:
      • Added criterion for routine prophylaxis use.
      • Removed age criterion consistent with product label
        • Medication is approved for use in children.
      • Expanded perioperative management of bleeding to include individuals with moderate hereditary factor X deficiency:
        • Consistent with product label
    • Enhanced Profilnine coverage criteria to include coverage for factor II and X deficiency:
      • Profilnine is a mixture of the vitamin K-dependent clotting factors IX, II, X with compendia off-label support for warfarin anticoagulation reversal.
    • Added criteria for Esperoct.
    • Enhanced Fibryga and RiaSTAP coverage criteria to confirm diagnosis by laboratory testing.
Compounded Medications - (1406) Modified
  • Important changes in coverage criteria:
    • Added compounded implantable hormone pellets as noncovered products.
    • Added bromocriptine mesylate and ondansetron hydrochloride to FDA exemption list.
    • Added mometasone furoate and fluticasone propionate to noncovered topical compounded list.
    • Added context to FDA exemption list.
    • Removed bulk ingredient statement from EIU section.
    • Removed EIU section from criteria.
Hereditary Transthyretin Amyloidosis Agents – (1901) Modified
  • Minor changes in coverage criteria/policy:
    • Reformatted diagnostic criterion to point towards documented genetic testing only.
    • Removed “Tissue Biopsy” criterion.
    • Moved differential diagnosis component to standalone criterion:
      • Previously included as part of the negative result tissue biopsy criterion tree.
    • Lengthened initial and re-authorization duration from 6 months to 12 months.
Idiopathic Pulmonary Fibrosis and Related Lung Disease Therapy – (1505) Modified
  • Retitled policy to incorporate new expanded indications of nintedanib (Ofev) beyond just idiopathic pulmonary fibrosis.
  • Removed criteria for rheumatologic workup for Esbriet since we require exclusion of “other potential causes” and added a pulmonologist prescriber requirement.
    • This allowed the combination/simplification of criteria statements for Ofev and Esbriet for the shared indication of idiopathic pulmonary fibrosis.
  • Developed medical necessity criteria in consultation with subject matter experts for nintedanib’s (Ofev) recently expanded FDA indications for systemic sclerosis-associated interstitial lung disease (SSc-ILD) and chronic fibrosing interstitial lung diseases (ILDs) with a progressive phenotype.
    • Both to include age of 18 and up, documented diagnosis with HRCT, specialist prescribing/or in consultation, and nonconcomitant use with Esbriet.
    • SSc-ILD criteria includes documented diagnosis of Systemic Sclerosis and chronic fibrosing ILDs include additional criteria for forced vital capacity (FVC) that demonstrate progressive nature of the disease.
  • Updated reauthorization criteria to add “pre-treatment” clinical condition met initial criteria, attestation of beneficial clinical response (which given the progressive nature of disease state could mean a “slowing” of progression or stabilization of condition), and continued prescribing or consultation with pulmonologist due to the complex nature of these diseases.
  • Reconciled policy to include addition of recommended ages for each indication, as well as “prescribed by or in consultation with a specialist (pulmonologist or rheumatologist)”.
Luspatercept – (2006) Modified
  • Important changes in coverage criteria, effective June 15, 2020:
    • Added medical necessity coverage criteria for Reblozyl (luspatercept):
      • New indication for treatment of anemia failing an erythropoiesis stimulating agent and requiring two or more red blood cell units over eight weeks in adult patients with very low- to intermediate-risk myelodysplastic syndromes with ring sideroblasts (MDS-RS) or with myelodysplastic/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T).
Lanreotide for Non-Oncology Indications – (9005) Modified
  • Minor changes in coverage criteria/policy:
    • Reformatted bullet point for acromegaly into current template language.
    • Removed bullet for “Perioperative management in pancreatic resection”
      • Pertains more to oncologic uses/indications of lanreotide, not addressed in policy.
    • Updated formatting of reauthorization statement and added bullet point for “Individual has had a positive clinical response”.
Oncology Medications – (1403) Modified
  • Important changes in coverage criteria, effective June 15, 2020:
    • Added new oncology medications to pharmacy benefit table (business decision):
      • Ontruzant.
      • Pemazyre.
      • Tukysa.
    • Added new oncology medication to medical benefit table (business decision):
      • Trodelvy.
    • Important changes in coverage criteria, posting June 15, 2020; effective July 1, 2020 (business decision):
      • Added Herzuma and Ontruzant to preferred products table, stepping medication behind the preferred brand products, Ogivri and Trazimera.
Ophthalmic Prostaglandin Analogs - (P0088) Modified
  • Minor changes in coverage criteria/policy:
    • Added diagnostic statement for each product:
      • Aligned to FDA labeled indications.
    • Added EIU statement, excluding use for cosmetic reasons.
Testosterone Therapy (Injectables and Implantable Pellets) – (1503) Modified
  • Important changes in coverage criteria, effective June 15, 2020:
    • Incorporated Testopel into policy and removed it from Implantable Hormone Pellets – (1504), which is being retired.
    • Removed oral, topical, and nasal products:
      • Added to new standalone policy Testosterone Therapy (Oral, Nasal, and Topical) – (2013).
      • Added hyperlink to the related coverage resources for the new policy.
    • Added clarification of assay type (equilibrium dialysis only) acceptable for free testosterone level:
      • In response to significant inconsistencies among various labs/assays used for free testosterone, which may lead to inappropriate approvals.
      • Equilibrium dialysis is the current gold standard defined in guidelines.
    • Added “No concurrent use of other testosterone products” statement based on subject matter expert feedback to avoid potential overutilization and safety concerns.
    • Changed Xyosted criteria to three alternatives:
      • Expanded formulary alternatives to list all formulary preferred testosterone gel products.
    • Added testosterone cypionate (Depo-testosterone) or testosterone enanthate injection (Delatestryl) for Xyosted as potential alternative.
    • Added EIU use “To enhance athletic performance or to increase muscle mass.”
Topical Acne – (P0049) Modified
  • Important changes in coverage criteria:
    • Added Arazlo (new product) coverage criteria to support noncovered medical necessity review; based on business decision.
Voriconazole – (4004) Modified
  • Minor changes in coverage criteria/policy:
    • Simplified criterion for use in HIV-infected individuals:
      • Broadened use to allow coverage for prophylaxis or treatment of systemic fungal infection.
      • Removed requirements for a step through covered alternatives.
Implantable Hormone Pellets – (1504) Retired
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for June 2020
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
COVID-19 Interim Billing Guidelines – (R33) Modified
  • Effective May 21, 2020:
    • Updated with ICD-10 codes for billing return-to-work and presurgical/preadmission testing.
    • Added guidance for interprofessional consultation code billing.
    • Clarified that virtual care services must be appropriate to render virtually.
    • Added C9083 to specimen collection table.
    • Extended end date for billing guidelines to July 31, 2020.
Policies Status Details
ClaimsXten*
  • No updates for June 2020.

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.