Policy Updates March 2022
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 |
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Policies | Status | Details |
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COVID-19: In Vitro Diagnostic Testing – (0557) | Modified |
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Gender Dysphoria Treatment – (0266) | Modified |
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Inflammatory Bowel Disease – Testing for the Diagnosis and Management – (0121) | Modified |
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Low-Level Laser and High-Power Laser Therapy – (CPG 030) | Modified |
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Miscellaneous Musculoskeletal Procedures – (0515) | Modified |
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Nucleic Acid Pathogen Testing – (0530) | Modified |
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Omnibus Codes – (0504) | Modified |
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Panniculectomy and Abdominoplasty – (0027) | Modified |
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Site of Care: High-tech Radiology – (0550) | Modified |
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Site of Care: Outpatient Hospital for Select Musculoskeletal Procedures – (0553) | Modified |
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Speech Generating Devices – (0049) | Modified |
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Speech Therapy – (0177) | Modified |
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Transthoracic Echocardiography in Adults – (0510) | Modified |
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Transthoracic Echocardiography in Children – (0523) | Modified |
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Vitamin D Testing – (0526) | Modified |
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Policies | Status | Details |
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Policies | Status | Details |
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Comprehensive Musculoskeletal Management (CMM) guidelines | Modified |
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Gastrointestinal Endoscopic Procedures guidelines | Modified |
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High-Tech Radiology (HTR or Imaging) guidelines | Modified |
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Policies | Status | Details |
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Policies | Status | Details |
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Unless otherwise noted, the following pharmacy coverage policies were modified effective March 1, 2022: | ||
Lorazepam Extended-Release – (IP0364) | New |
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Tofacitinib - (IP0230) | New |
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Delafloxacin – (IP0373)
Goserelin Acetate Subcutaneous Implant - (IP0353) Lonapegsomatropin - (IP0375)
Metreleptin - (IP0340) Oxazolidinone Antibiotics – (IP0372)
Testosterone (Injectables and Implantable Pellets) – (IP0351)
Testosterone (Oral, Topical, and Nasal) – (IP0350)
Ustekinumab Subcutaneous - (IP0239)
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New |
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Efgartigimod - (IP0376) Hydroxyprogesterone Caproate Injection – (IP0370)
Inclisiran - (IP0380) Plasminogen - (IP0382) Protein C Concentrate - (IP0342)
Rituximab for Non-Oncology Indications – (IP0319)
Triamcinolone Acetonide Ophthalmic - (IP0371) Ustekinumab Intravenous - (IP0240)
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New |
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FEIBA – (IP0354) Fibrinogen Products – (IP0357)
NovoSeven RT – (IP0356) Sevenfact – (IP0355) |
New |
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Clotting Factors and Antithrombin – (8007) | Modified |
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COVID-19 Drug and Biologic Therapeutics - (2016) | Modified |
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Immune Globulin - (5026) | Modified |
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Immunomodulators - Oral and Subcutaneous (Cigna Total Savings Drug List) - (2102) Immunomodulators – Oral and Subcutaneous (Individual and Family Plans) - (1903) Immunomodulators – Oral and Subcutaneous (Standard/ Performance, Value/ Advantage, Legacy Drug List Plans) - (1805) |
Modified |
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Medication Administration Site of Care - (1605) | Modified |
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Migraine Treatment – (IP0029) | Modified |
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Pharmacy Prior Authorization – (1407) | Modified |
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Routine Immunizations - (9001) | Modified |
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Secukinumab - (IP0223) | Modified |
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Upadacitinib - (IP0229) | Modified |
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Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use – (1206) | Modified |
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Delafloxacin – (P0045) | Retired |
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Hydroxyprogesterone Caproate Injection – (1108) | Retired |
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Oxazolidinone Antibiotics – (1123) | Retired |
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Protein C Concentrate - (1604) | Retired |
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Rituximab for Non-Oncology Indications - (5108) | Retired |
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Testosterone Therapy (Injectables and Implantable Pellets) – (1503) | Retired |
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Testosterone Therapy (Oral, Nasal, and Topicals) – (2013) | Retired |
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Policies | Status | Details |
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Policies | Status | Details |
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Policies | Status | Details |
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Policies | Status | Details |
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Policies | Status | Details |
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Care Integration Services – (R32) COVID-19 Interim Billing Guidelines – (R33) Facility Routine Services, Supplies, and Equipment – (R12) Omnibus Reimbursement Policy – (R24) |
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Policies | Status | Details |
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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.