Policy Updates March 2016

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective March 15, 2016:
Electroencephalography - (0521) New
  • Information about this new coverage policy previously shared on December 15, 2015 to provide advance notifcation to health care professionals.
    • New coverage policy posted on March 15, 2016.
    • Update coverage begins April 11, 2016.
    • Previous policy version was removed from Coverage Policy Alpha Index on March 15, 2016.
    • Coverage policy developed for ambulatory electroencephalography (EEG) and EEG digital spike analysis.
  • Important changes in coverage:
    • Changed from covered to not covered:
      • Currently allow both ambulatory electroencephalography (EEG) and EEG digital spike analysis without restriction.
      • Procedure to diagnosis (PXDX) lever will be used for ambulatory EEG.
      • Procedure to procedure (PXPX) lever will be used for EEG digital spike analysis.
Acupuncture - (0024) Modified
  • Policy statement updates with no change in coverage:
    • Added statement to existing disclaimer noting maintenance care is excluded.
    • Added statements, consistent with benefit language and other therapy-related policies (physical therapy, occupational therapy, and chiropractic treatment):
      • requiring therapeutic improvement over a clearly defined period of time;
      • individualized treatment plan with goals, frequency, and duration;
      • treatment to improve physical condition is excluded and not medically necessary;
      • maintenance care is excluded and not medically necessary.
    • Combined existing experimental, investigational, unproven (EIU) policy statements into one.
Bone Graft Substitutes for Use in Bone Repair - (0118) Modified
  • Policy statement updates with no change in coverage:
    • Added disclaimer that some bone graft materials are not clinically superior, despite advanced processing methods:
      • For those materials, "least costly alternative" language may apply.
    • Added amniotic fluid stem cells to existing EIU bullet for human amniotic membrane materials.
    • Clarified language to cell-based materials to include "used alone, seeded onto a scaffold, and/or added to other biomaterials."
Gender Reassignment Surgery - (0266) Modified
  • Important changes in coverage:
    • Updated criteria in policy statements for genital surgery to require referral from two mental health professionals.
      • Removed requirement for one master's degree and one psychiatrist or PhD clinical psychologist.
  • Policy statement update with no change in coverage:
    • Defined credentials required for mental health professional as a disclaimer.
Hospice Care - (0462) Modified
  • Policy statement update with no change in coverage:
    • Clarified definition of "activities of daily living" to include
      • personal hygiene,
      • feeding,
      • dressing, and
      • transfers.
Implantable Cardioverter Defibrillator (ICD) - (0181) Modified
  • Policy statement update with no change in coverage:
    • Updated existing transvenous implantable cardioverter defibrillator criterion:
      • Was New York Heart Association (NYHA) class II - III.
      • Now reads NYHA I - III.
Omnibus Codes - (0504) Modified
  • Policy statement update with no change in coverage:
    • Incorporated content from Coma Stimulation - 0272 coverage position.
      • Coma Stimulation - 0272 will be retired.
Speech Generating Devices - (0049) Modified
  • Policy statement update with no change in coverage:
    • Clarified description of speech generating devices in existing covered and not covered policy statements.
Wearable Cardioverter Defibrillator and Automatic External Defibrillator - (0431) Modified
  • Policy statement update with no change in coverage:
    • Updated existing transvenous implantable cardioverter defibrillator criterion:
      • Was NYHA class II - III.
      • Now reads NYHA I - III.
Coma Stimulation - (0272) Retired
Two additional policies retired: Retired
  • Extracorporeal Electromagnetic Stimulation for Urinary Incontinence - (0041)
  • Transcranial Doppler (TCD) Ultrasonography - (0345)
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective March 15, 2016:
Hepatitis C Therapy - (1316) Modified
  • Important changes in coverage:
    • Removed criteria requirements "absence of active use of illicit intravenous drugs" and "absence of active alcohol abuse."
      • Change based on recent updates to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidance.
Histrelin Acetate Subcutaneous Implant (Supprelin LA) - (8008) Modified
  • Important changes in coverage:
    • Added coverage for gender dysphoria in adolescents using Endocrine Society's criteria.
      • Several sources note that gonadotropin-releasing hormone (GnRH) analogs such as histrelin have evolved into accepted use for pubertal suppression in transgender adolescents/gender dysphoria.
    • Added standard coverage policy statement to address that all other uses are considered EIU.
Omalizumab (Xolair®) - (4026) Modified
  • Important changes in coverage:
    • Added "NOTE: Receipt of sample product does not satisfy any criteria requirement for coverage."
    • In Asthma section:
      • Removed "Inadequate control with inhaled corticosteroid (ICS)."
      • Added "Inadequately controlled with (or not a candidate for) a moderate dose of inhaled corticosteroids plus long-acting beta-agonists or leukotriene receptor antagonist for at least 3 months."
      • Revised "Regular use of an ICS AND another controller therapy such as a long-acting beta agonist or leukotriene receptor antagonist" to "Continued use of an ICS AND another controller therapy such as a long-acting beta agonist or leukotriene receptor antagonist with add-on omalizumab (Xolair)."
      • Added "Laboratory data reflecting IgE levels greater than 30 but less than 1500 IU/ml."
    • In Chronic Idiopathic Urticaria section:
      • Added "Xolair will not be approved in combination with other monoclonal antibodies (e.g., Nucala┬«)."
      • Added doxepin:
        • Changed language to: "failure or inadequate response, contraindication per FDA label, documented intolerance, or not a candidate for".
Pharmacy Prior Authorization - (1407) Modified
  • Important changes in coverage:
    • Added XuridenTM (uridine triacetate).
Step Therapy - (1109) Modified
  • Important changes in coverage:
    • Added QuilliChew ERTM (methylphenidate chewable table) to Global Step Therapy under ADHD.
Policies Status Details
Administrative Policies
There were no administrative policy updates for March.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Nineteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
Policies Status Details
Reimbursement Policies*
R11 Global Maternity/ Obstetric Package Modified
  • Important changes:
    • Removed ICD10 codes Z30.011, Z30.09, and Z3A.00-Z3A.49.
R26 Physician Interpretation and Report (I&R) Services Modified
  • Important changes:
    • Added CPT code 76604 as an exception to the edit:
    • Code will be allowed when billed in addition to an emergency room E&M visit.
Policies Status Details
Claim Editing Policies and Procedures ClaimsXten
No updates for March 2016
Policies Status Details
Policies with a Reduction in Coverage**
There were no additional policy updates that resulted in a reduction in coverage for March.

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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**The following policy updates, effective March 15, 2016, will result in a reduction of coverage.