Policy Updates March 2018

Important New 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 Details
Policies with a Reduction in Coverage
We are changing how we reimburse for the following policies for claims processed or dates of service on or after March 19, 2018.

Continuous Passive Motion (CPM) Devices (0198)

  • We updated our coverage policy and willdeny claims for a CPM device (Healthcare Common Procedure Coding System code E0935) billed with diagnosis codes Z96.651-Z96.659 following knee joint replacement as being experimental, investigational, and unproven (EIU).

Vitamin D Testing (0526) (new)

  • We created a new coverage policy and will reimburse claims for vitamin D testing billed with Current Procedural Terminology (CPT®) codes 82306 or 82652 when considered medically necessary, and for select population groups (under age 18 or over age 65, and pregnant women).
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective March 15, 2018:
Cervical Fusion – (0527) New
  • Advance posting of policy effective June 15, 2018:
    • Supports anterior and posterior cervical fusion.
    • Implemented through precertification.
    • 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.
    • Considered not medically necessary for the following:
      • With initial primary laminectomy/discectomy for nerve root decompression or spinal stenosis in the absence of spondylolisthesis or kyphosis.
      • For the 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.
Vitamin D Testing - (0526) New
  • Provided advance notification on December 15, 2017; policy effective March 15, 2018:
    • Addresses serum Vitamin D testing.
    • Implemented with a procedure-to-diagnosis (PXDX) edit on CPT codes 82306 and 82652:
      • Allows payment for certain diagnoses only.
      • All other diagnosis codes denied as not medically necessary.
      • Edit does not apply to ages 17 and under, 65 and older, and pregnant women.
    • Removing 82306 from preventive supplemental list.

Continuous Passive Motion (CPM) Devices - (0198)

Modified
  • Reminder of important changes in coverage criteria:
  • Provided advance notification on December 15, 2017; changes effective March 15, 2018:
    • Changed from covered to not covered following knee replacement:
      • Turned off PXDX edit that allows E0935 (CPM knee) with ICD10 Z96.651-Z96.659 (Presence of artificial knee joint).
      • Moved E0935 to always experimental, investigational or unproven (EIU) for all diagnosis codes.
    • Code E0936 (CPM other than knee) remains always EIU for all diagnosis codes.
Implantable Cardioverter Defibrillator - (0181) and Wearable Cardioverter Defibrillator and Automatic External Defibrillator – (0431) Modified
  • Important changes in coverage criteria:
    • Aligned subcutaneous implantable cardioverter defibrillator (ICD) policy statement with the 2017 American Heart Association/American College of Cardiology (AHA/ACC) guideline for the management of patients with ventricular arrhythmias and prevention of sudden cardiac death.
Miscellaneous Musculoskeletal Procedures – (0515) Modified
  • Important changes in coverage criteria:
    • Moved to a silent position to allow coverage for custom knee implants / instrumentation / replacement.
    • Removed preoperative imaging verbiage:
      • Added policy statement to applicable Cigna-eviCore cobranded imaging guideline.
    • Removed sections on bone or cartilage filler materials and ligament/meniscus reconstruction:
    • Added policy statement for ankle subchondroplasty:
      • No change to coverage.
    • Reformatted policy statement for healing response microfracture:
      • No change to coverage.
Pharmacogenetic Testing - (0500) Modified
  • Important change in coverage criteria:
    • Added coverage of multigene panel genetic testing if medical necessity criteria for at least one gene are met and panel test is contracted with Cigna.
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; effective June 15, 2018:
    • Added specific criteria defining symptomatic and antiarrhythmic medication use.
      • Applicable codes will be added to precertification list.
Policies Status Details
Cigna-ASH Coverage Policy Guidelines
  • No updates for March 2018.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Policies Status Details
Administrative Policies
  • No updates for March 2018.
  • Policies Status Details
    Pharmacy (Drugs & Biologics) Policies
    The following pharmacy (drugs & biologics) coverage policies were modified effective March 15, 2018:
    Clotting Factors and Antithrombin - (8007) Modified
    • Important changes in coverage criteria:
      • Added three new products:
        • Fibryga, Hemlibra and Rebinyn.
      • Updated Alphanate® criteria to remove limitation of use to an adult:
        • FDA approved for adults and children.
      • Updated Idelvion criteria to align with FDA indication.
      • Removed Kcentra®:
        • Does not require precertification.
    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 criteria for Admelog, Fiasp and Gocovri.
      • Modified Victoza criteria to add not a candidate language referring to alternatives.
      • Modified Locoid criteria to add additional dosage forms.
    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 criteria for Admelog, Fiasp and Gocovri.
      • Modified Victoza criteria to add not a candidate language referring to alternatives.
    Histrelin acetate subcutaneous implant - (8008) Modified
    • Important changes in coverage criteria:
    Interferon Therapy - (1315) Modified
    • Important changes in coverage criteria:
      • Expanded Pegasys criteria to cover new FDA indication for treatment of HBeAg-positive chronic hepatitis B in non-cirrhotic pediatric patients three years of age and older with evidence of viral replication and elevations in serum alanine aminotransferase (ALT).
      • Clarified Clarified chronic hepatitis B criteria to align with FDA product label.
      • Added Bechet’s disease, chronic uveitis and vernal keratoconjunctivitis to the not covered EIU list.
    Omalizumab - (4026) Modified
    • Important changes in coverage criteria:
      • Extended authorization and re-authorization duration from 6 months to 12 months in chronic idiopathic urticarial (CIU) to address concerns of insufficient time to fulfill re-authorization criteria.
      • Clarified dose reduction in CIU re-authorization criteria to include decrease in dose frequency.
    Pharmacy Prior Authorization - (1407) Modified
    • Important changes in coverage criteria:
      • Modified criteria for Procysbi down to one year of age due to FDA expanded indication and strengthened diagnosis criteria.
      • Added criteria for Symproic to mirror FDA indication for Opioid Induced Constipation:
        • Removed from 180 day hold and added to prior authorization.
      • Added statement that use of leuprolide (Lupron Depot) for gender dysphoria is addressed in Treatment of Gender Dysphoria – (0266).
    Step Therapy Individual and Family Plans – (1603) Modified
    • Important changes in coverage criteria:
      • Removed five products that are California formulary-specific:
        • Rexulti, Kazano, Oseni, Janumet® and Janumet XR.
    Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use - (1206) Modified
    • Important change in coverage criteria:
      • Modified criteria for diabetic retinopathy for Lucentis following FDA approval of expanded indication.
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    No updates for March 2018.
    Policies Status Details
    Precertification Policies*
    Policies Status Details
    Reimbursement Policies*
    Policies Status Details
    Claim Editing Policies and Procedures* ClaimsXten
    No updates for March 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.