Policy Updates March 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
Policies With a Reduction in Coverage
Evaluation and Management Services - (R30)*
  • We will update the Evaluation and Management Services (R30) reimbursement policy.
  • Effective for claims processed on or after March 16, 2020, we will require documentation to review the appropriate use of billing for evaluation and management (E&M) services when billed with codes for a joint injection or aspiration. Reimbursement for the E&M codes may be denied.
  • Only the line item for the E&M code(s) will be denied.
  • We will deny reimbursement for E&M services billed with CPT code 99211 appended with modifier 25 when billed alone or with another procedure code on the same date of service.
  • Only the line item for CPT code 99211 appended with modifier 25 will be denied. Services billed with other codes on the same claim will be reimbursed according to the terms of our policies and the provider’s agreement.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective March 15, 2020:
Stem Cell Therapy for Orthopaedic Applications – (0552) New
  • Originally provided advance notification on December 15, 2019, policy effective March 15, 2020.
    • New experimental, investigational, or unproven (EIU) policy statement for stem cell therapy treatment of orthopaedic and/or musculoskeletal conditions.
Breast Reconstruction Following Mastectomy or Lumpectomy - (0178) Modified
  • Important changes in coverage criteria:
    • Added coverage for Cortiva.
    • Added GalaSHAPE 3D scaffold to existing EIU policy statement.
    • Clarified statement re: adipose-derived stem cells.
Cardiac Rehabilitation (Phase II Outpatient) - (0073) Modified
  • Minor changes in coverage criteria/policy:
    • Clarified current wording.
Complementary and Alternative Medicine - (0086) Modified
  • Minor changes in coverage criteria/policy:
    • Clarified martial arts therapy in existing EIU policy statement.
Electroencephalography – (0521) Modified
  • Minor changes in coverage criteria/policy:
    • Clarified existing policy statement.
Endometrial Ablation - (0013) Modified
  • Advance notification of important changes in coverage criteria, effective June 15, 2020:
    •  We will deny claims submitted with Current Procedural Terminology (CPT®) codes 58353, 58356, and 58563 for endometrial ablation when billed with certain diagnoses as being considered experimental, investigational, or unproven (EIU).
Implantable Cardioverter Defibrillator (ICD) – (0181) Modified
Inpatient Acute Rehabilitation - (0427) Modified
  • Minor change in coverage criteria/policy:
    • Updated existing policy statement criteria to be consistent with Centers for Medicare and Medicaid Services (CMS).
Miscellaneous Musculoskeletal Procedures – (0515) Modified
  • Important change in coverage criteria:
    • Removed minimally invasive knee replacement from EIU section.
Panniculectomy and Abdominoplasty - (0027) Modified
  • Important changes in coverage criteria:
    • Edited criteria related to skin conditions to align with Redundant Skin Surgery – (0470):
      • Removed requirement of at least one episode of cellulitis requiring systemic antibiotics.
    • Added policy statement addressing correction of diastasis recti.
Plantar Fasciitis Treatments - (0097) Modified
  • Important changes in coverage criteria:
    • Added two items to existing EIU policy statement.
Tilt Table Testing - (0066) Modified
  • Minor change in coverage criteria/policy:
    • Updated existing policy statement re: provocative agents.
Tissue-Engineered Skin Substitutes - (0068 Modified
  • Important changes in coverage criteria:
    • Added 28 new products as EIU.
    • Added coverage for Cortiva for breast reconstruction.
    • Added coverage for Grafix for venous leg ulcers.
Total Ankle Arthroplasty/Replacement - (0285) Modified
  • Important changes in coverage criteria:
    • Clarified FDA-approved device.
    • Updated pain criteria language.
    • Removed customized/gender language and pre-op imaging language/codes.
    • Added EIU policy statement for total talar prosthesis implantation.
    • Removed CPT code 27700 (Arthroplasty, ankle)
      • Not in scope of policy.
    • Added CPT code 27704 (Removal of ankle implant)
      • In scope of policy.
Transcranial Magnetic Stimulation - (0383) Modified
  • Important changes in coverage criteria:
    • Updated criteria statement from failure of three antidepressant trials to failure of two antidepressant trials.
    • Clarified criteria wording for repeat transcranial magnetic stimulation.
Transthoracic Echocardiography in Adults - (0510) Modified
  • Advance notification of important changes in coverage criteria, 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.
      • The newer AUCs are driving significant policy reformatting.
    • Added new policy statement to approve myocardial strain imaging (new Jan 2020 add-on CPT code 93356) before, during or following exposure to medications/radiation that could result in cardiotoxicity.
    • Added new policy statement addressing frequency of TTE, which states that 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.
Transthoracic Echocardiography in Children – (0523) Modified
  • Advance notification of important changes in coverage criteria, 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 (new Jan 2020 add-on CPT code 93356) before, during or following exposure to medications/radiation that could result in cardiotoxicity.
    • Added new policy statement noting TTE as a screening study before starting ADHD drugs is considered NMN.
Wearable Cardioverter Defibrillator and Automatic External Defibrillator - (0431) Modified
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • No new policies for March 2020
Policies Status Details
Cigna-eviCore Cobranded Guidelines
  • The following Comprehensive Musculoskeletal Management (CMM) guidelines have been updated:
    • Regional Sympathetic Blocks – (CMM 209)
      • No changes
    • Epidural Steroid Injection – (CMM 200)
    • Hip Replacement Arthroplasty – (CMM 313)
    • Hip Surgery Arthroscopic and Open Procedures – (CMM 314)
    • Knee Replacement Arthroplasty – (CMM 311)
Policies Status Details
Administrative Policies
  • No new policies for March 2020
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective March 1, 2020:
Colchicine – (P0119) – effective March 17, 2020. New
  • Supports noncoverage of Gloperba colchicine solution.

Midazolam Nasal Spray – (P0108) – effective March 10, 2020.

Pitolisant – (P0111) – effective March 25, 2020.

New
  • Supports pharmacy prior authorization requirements.
Antivirals, Topical – (P0051) Modified
  • Important changes in coverage criteria:
    • Added coverage criteria for generic acyclovir cream aligned with criteria currently in use for brand Zovirax cream:
      • Generic formulation available in marketplace since last annual review cycle.
    • Expanded diagnosis criterion for acyclovir (generic and brand) ointment to include coverage for mucocutaneous herpes simplex virus infections in immunocompromised patients.
Authorized Generics - (A008) Modified
  • Important changes in coverage criteria:
    •  Added Symbicort brand and Symbicort authorized generic:
      • Business decision to only cover the brand on all employer group formularies.
    • Added Aczone and dapsone 7.5 % gel pump authorized generic:
      • Business decision to only cover the brand on Legacy formulary.
    • Added Sorilux 0.01% foam and Calcipotriene authorized generic:
      • Business decision to only cover the brand on Standard, Performance, and Legacy formularies.
Elagolix – (P0065) Modified
  • Important changes in coverage criteria, effective April 1, 2020:
    • Added additional criteria for use of one progestin or combined oral contraceptives or prior use of gonadotropin-releasing hormone agonist to employer group plan criteria to align with current guidelines.
    • Added “*may require prior authorization” note to individual family plans as listed alternatives, where applicable.
Epinephrine – (P0003) Modified
  • Important changes in coverage criteria:
    • Reformatted criteria stem into table format to consolidate and simplify for ease of use and readability.
    • Added Symjepi prefilled syringes to policy.
    • Removed “intolerance” from criteria because all products contain same active and inactive ingredients as epinephrine auto-injector.
    • Removed “inability to use” because ease of use with auto-injector is expected to be greater than with prefilled syringe manual injection product, such as Symjepi.
    • Removed “intolerance” and “inability to use” from Auvi-Q criteria:
      • Product contains same active and inactive ingredients as generic epinephrine auto-injector.
    • Removed EIU statement from criteria stem:
      • Policy relates to product preference for generic epinephrine injections and criteria does not pertain to diagnosis/indications or other uses.

Immunomodulators – Oral and Subcutaneous (Employer Group Benefit Plans) – (1805) and

Immunomodulators – Oral and Subcutaneous (Individual and Family Plan) – (1903)

Modified
  • Important changes in coverage criteria:
    • Added step-through of Humira for Xeljanz and Stelara responsive to business decision; Simponi step through must be Humira for ulcerative colitis.
    • Added Xeljanz XR responsive to an expanded FDA indication approval for ulcerative colitis.
    • Corrected Stelara intravenous formulation for Ulcerative Colitis – Adults:
      • Allowed for single infusion per FDA dosing recommendations.
Omega-3 Fatty Acids – (P0099) Modified
  • Important changes in coverage criteria:
    • Decreased for hypertriglyceridemia indication from four formulary alternatives down to two formulary alternatives, generic Lovaza and one of the following based on insight provided upon reconciliation of the policy with current P&T guidance:
      • Fibrate
      • Niacin
      • Statin
    • Added criteria previously approved at committee for new FDA indication of “Cardiovascular Event Risk Reduction”.
Opioid Therapy - (1704) Modified
  • Important changes in coverage criteria:
    • Removed Embeda:
      • Product discontinued.
    • Moved Morphabond from nonpreferred brand to preferred brand.
Pegfilgrastim – (1320) Modified
  • Important changes in coverage criteria:
    • Added Ziextenzo coverage criteria:
      • Business to co-prefer to Neulasta, Fulphila, and Udenyca.
Tasimelteon - (P0018) Modified
  • Important changes in coverage criteria:
    • Updated indication statement by requiring a documented diagnosis.
    • Added specialist prescribing requirement.
    • Added step-through guideline recommended melatonin.
    • Decreased initial authorization time limit to six months.
    • Added reauthorization time limit of 12 months.
    • Expanded EIU uses.
Topical Acne – (P0049) Modified
  • Important changes in coverage criteria, effective March 17, 2020:
    • Added Amzeeq (minocycline 4%) topical foam with coverage criteria:
      • Business decision to remain noncovered.
Weight Loss Medications – (P0104) Modified
  • Important changes in coverage criteria, effective March 15, 2020:
    • Removed Belviq/Belviq XR (lorcaserin):
      • Products being removed from market because a safety clinical trial showed an increased risk of cancer.
    • Updated Saxenda criteria:
      • Removed Belviq and Belviq XR as an alternate for employer group plans.
Zolgensma® (Onasemnogene Abeparvovec-axgt) - (1904) Modified
  • Important changes in coverage criteria:
    • Added premature neonate full-term gestation age be met requirement secondary to patient safety.
    • Added additional documentation requirements to several criterion.
    • Added submission of medical records as a criterion, replacing the “Note”.
    • Added background information re: use in premature neonates.
    • Updated all “Abeparvocec-axgt” to “Abeparvovec-xioi” including title change as described in the FDA label
      • Posting information from this bullet on March 15, 2020.
Aztreonam Inhalation – (P0061) Retired
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for March 2020
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Virtual Care – (R31) New
  • Advance notification of policy effective June 15, 2020:
    • Outlines required billing for virtual care reimbursement:
      • Providers must bill one of the codes in the policy along with place of service (POS) 02 and modifier 95 or GT to receive reimbursement for services rendered virtually.
Care Integration Services – (R32) Modified
  • Important changes, effective March 16, 2020:
    • Added new codes G2058, G2064, G2065, and G0512.
Genetic Testing Panels – (R28) Modified
  • Advance notification of important changes, effective May 18, 2020:
    • Updated to note nucleic acid sexually transmitted disease panels (CPT 87800 and 87801) are subject to unbundling edits.
      • In the event that multiple panel specific units are identified on a claim(s) from the same provider on the same date of service, the individual genetic testing codes will be rebundled and reimbursement will be made based on the panel code(s) which are similar to and more accurately reflects the service provided.
Omnibus Reimbursement Policy – (R24) Modified
  • Advance notification of important changes, effective February 20, 2020:
    • Added statement for perfusion assessment:
      • Assessment of perfusion by any technology including but not limited to intraoperative fluorescent angiography, indocyanine green (ICG) fluorescence angiography or SPY® Fluorescent Imaging System is integral to the primary procedure and is not separately reimbursed.
Policies Status Details
ClaimsXten*
  • No updates for March 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.