Policy Updates March 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective March 15, 2017:
Autonomic Nerve Function Testing – (0506) Modified
  • Important changes in coverage criteria:
    • Added not covered policy statement for autonomic nerve function testing using portable, automated devices.
Implantable Cardioverter Defibrillator (ICD) – (0181) Modified
  • Important changes in coverage criteria:
    • Added leadless cardiac pacemaker policy statement, background information, and coding removed from Omnibus Codes - (0504).
      • CPT® codes 0387T – 0391T.
Omnibus Codes - (0504) Modified
Treatment of Gender Dysphoria – (0266) Modified
  • Important changes in coverage criteria:
    • Changed title:
      • Previously “Gender Reassignment Surgery”.
    • Added coverage for penile prosthesis and surgical correction of same.
    • Expanded policy scope to include reference to behavioral health services and drug and biologic services.
Tumor Profiling, Gene Expression Assays, and Molecular Diagnostic Testing for Hematology/Oncology Indications - (0520) Modified
  • Important changes in coverage criteria:
    • Added criteria to existing coverage policy statement for tumor biomarker or gene expression classifier test.
    • Added criteria to existing coverage policy statement for tumor profile/gene expression classifier testing for Oncotype DX™ Breast Cancer Assay.
    • Added coverage policy statement for tumor profile/gene expression classifier testing for cobas® EGFR Mutation Test v2 for non-small cell lung cancer (NSCLC).
    • Added policy statements/criteria under the Hematologic Cancer and Myeloproliferative and Myelodysplastic Disease section.
Wearable Cardioverter Defibrillator and Automatic External Defibrillator – (0431) Modified
  • Important changes in coverage criteria:
Convection-Enhanced Delivery of Therapeutic Agents to the Brain – (0476) Retired
Transarterial Chemoembolization - (0282) Retired
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy (drugs & biologics) coverage policies were modified effective March 15, 2017:
Clotting Factors and Antithrombin - (8007) Modified
  • Important changes in coverage criteria:
    • Added four recently approved products in accord with their previously approved interim criteria:
      • Kovaltry, Afstyla, Idelvion, and Vonvendi.
    • Updated criteria for Adynovate due to FDA indication expansion:
      • Previously approved as interim criteria.
  • Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List - (1601) Modified
    • Important changes in coverage criteria:
      • Added Adrenaclick, EpiPen, EpiPen Jr., and GoNitro.
      • Removed Novacort:
        • Not an FDA-approved product; therefore, is benefit excluded.
    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:
      • Added Adrenaclick, EpiPen, EpiPen Jr., and GoNitro.
      • Removed Novacort:
        • Not an FDA-approved product; therefore, is benefit excluded.
    Filgrastim - (1611) Modified
    • Important changes in coverage criteria:
      • Added criteria for documented failure or inadequate response with preferred products.
      • Specified hematopoietic cell transplant as a population allowing Neupogen use over preferred products.
      • Provided examples of not a candidate (pediatric individuals) and inability to use (dose is less than 180 mcg) for Neupogen use over preferred products.
    Implantable Hormone Pellets – (1504) Modified
    • Important changes in coverage criteria:
      • Added quantity limit for Testopel based on FDA-recommended dosing.
    Octreotide for Non-Oncology Indications - (5015) Modified
    Omalizumab - (4026) Modified
    • Important changes in coverage criteria:
      • Updated age criteria for asthma to align with expanded FDA indication for children six years of age and older.
      • Expanded reauthorization criteria for chronic idiopathic urticaria to include continued concomitant therapy with an H1 antihistamine.
    Oncology Medications - (1403) Modified
    • Important changes in coverage criteria:
      • Clarified specific criteria for Xtandi (enzalutamide) that preference for Zytiga (abiraterone) is only applicable when use is castration-recurrent metastatic prostate cancer.
      • Added Sandostatin/Sandostatin LAR (octreotide) and Actemra intravenous (tocilizumab) for oncology uses and rucaparib (Rubraca).
    Voriconazole - (4004) Modified
    • Important changes in coverage criteria:
      • Consolidated criteria for aspergillosis, candida, and cryptococcosis infections.
      • Expanded coverage to include treatment of coccidioidomycosis and histoplasmosis as a second-line agent for individuals without HIV-infection.
    Policies Status Details
    Administrative Policies
    No updates for March 2017.
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    Various Modified Seventeen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
    *Please log in to view these policies.
    Policies Status Details
    Precertification Policies*
    No updates for March 2017.
    Policies Status Details
    Reimbursement Policies*
    Updates have been made to the following policy:
    R01 Multiple Procedure Reduction - Radiology Modified
    Policies Status Details
    Claim Editing Policies and Procedures* ClaimsXten
    No updates for March 2017.
    Policies Status Details
    Policies with a Reduction in Coverage
    We are changing how we reimburse for Excessive Unit J Codes for claims processed on or after March 17, 2017.
    Excessive Unit J Codes
  • To ensure consistency with the Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual, outpatient uniform billing (UB) claim forms must include the correct Healthcare Common Procedure Coding System (HCPCS) units to bill for injectable drugs. Claims submitted using dosage units will be corrected to be reimbursed based on HCPCS units.

  • 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.