Policy Updates March 2022

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Policies Update to Coverage
Policies With a Reduction in Coverage
  • No updates for March 2022.
Policies Status Details
Medical Coverage Policies
  • Unless otherwise noted, the following medical coverage policies were modified effective March 15, 2022:
COVID-19: In Vitro Diagnostic Testing – (0557) Modified
  • Important changes in coverage criteria:
    • Added criterion related to at-home, over-the-counter (OTC) rapid antigen testing.
    • Clarified when in vitro testing (i.e., molecular, antigen, antibody) is considered not diagnostic and not covered.
Gender Dysphoria Treatment – (0266) Modified
  • Important changes in coverage criteria:
    • Changed title from “Treatment of Gender Dysphoria” to current title.
    • Updated policy statement to address initial mastectomy for individuals under age 18.
Inflammatory Bowel Disease – Testing for the Diagnosis and Management – (0121) Modified
  • Important changes in coverage criteria:
    • Changed title from Serological Testing for Inflammatory Bowel Disease to current title.
    • Moved coverage statement on fecal calprotectin (FC) from Omnibus Codes – (0504).
    • Changed position on using FC for management of inflammatory bowel disease (IBD) from experimental, investigational or unproven (EIU) to covered.
    • Added “and/or genetic” to statement on testing for serological markers.
    • Added additional biomarkers as EIU:
      • IBDX tool.
      • PROMETHEUS® Monitr test.
      • PredictSURE.
    • Removed infliximab and adalimumab from policy statement referring to serum drug levels and/or antibodies.
    • Changed wording of policy statement pertaining to serum drug levels and/or antibodies to:
      • “Therapeutic drug monitoring (TDM) used for the management of inflammatory bowel disease, including serum drug levels and/or antibodies, performed individually or as part of a test panel (e.g., Prometheus® Anser®, LabCorp DoseASSURE™) is considered experimental, investigational or unproven for the following biologic agents:”
    • Maintained EIU position for biologics.
Low-Level Laser and High-Power Laser Therapy – (CPG 030) Modified
  • Important change in coverage criteria:
    • Added policy statement for prevention of oral mucositis.
Miscellaneous Musculoskeletal Procedures – (0515) Modified
  • Important change in coverage criteria:
    • Added xenograft implantation of articular surface to existing EIU policy statement:
      • New CPT code 0737T, effective July 1, 2022.
Nucleic Acid Pathogen Testing – (0530) Modified
  • Important changes in coverage criteria:
    • Clarified wording about sexually transmitted infections in existing policy statement.
    • Clarified that the not medically necessary policy statement is addressing an outpatient level of care setting.
Omnibus Codes – (0504) Modified
  • Important changes in coverage criteria:
    • Added two sections for new codes to cardiovascular section:
      • Catheter, transluminal intravascular lithotripsy, coronary HCPCS code C1761:
        • New code, effective July 1, 2021.
        • Considered EIU.
      • Ultrafiltration CPT code 0692T:
        • New code, effective January 1, 2022:
        • Considered EIU.
    • Re-adding procedure to urology section:
      • Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance:
        • New codes, effective January 1, 2022:
          • CPT codes 53451, 53452, 53453, and 53454.
            • CPT codes replace CAT III codes.
          • Procedure remains EIU.
Panniculectomy and Abdominoplasty – (0027) Modified
  • Minor change in coverage criteria/policy:
    • Clarified that suction-assisted lipectomy used in conjunction with panniculectomy is not separately reimbursed and is considered integral to primary procedure.
Site of Care: High-tech Radiology – (0550) Modified
  • Important changes in coverage criteria, effective February 18, 2022:
    • Clarified existing policy statements:
      • eviCore uses our coverage policy to assess if an individual’s condition requires hospital-based imaging vs. free-standing imaging facility.
Site of Care: Outpatient Hospital for Select Musculoskeletal Procedures – (0553) Modified
  • Minor changes in coverage criteria/policy:
    • Minor clarifications to criteria wording.
Speech Generating Devices – (0049) Modified
  • Important changes in coverage criteria:
    • Speech generating devices (SGD) accessories section:
      • Clarified when individual already has an SGD and it is not being provided at the same time as the SGD accessory.
    • Not medically necessary section:
      • Clarified use of dedicated tablet (e.g., iPads) as use of an SGD.
      • Added criterion to address tablets (e.g., iPads) that are dedicated SGD.
Speech Therapy – (0177) Modified
  • Important change in coverage criteria:
    • Updated existing policy statement on group speech therapy:
      • Added group speech therapy to precertification, effective January 1, 2022.
Transthoracic Echocardiography in Adults – (0510) Modified
  • Important changes in coverage criteria:
    • Updated existing policy statements based on new/updated American College of Cardiology (ACC) guidelines:
      • Added coverage for scenario of chest pain and suspected myopericarditis.
      • Expanded coverage of transthoracic echocardiography (TTE) for re-evaluation (6–12 months) of asymptomatic mitral valve regurgitation (MR) to include severe stage B (in addition to stage C1).
      • Expanded coverage of TTE in patients with bioprosthetic valve from once at 10 years postop, to at 5 years, at 10 years, and then annually.
      • Expanded coverage of TTE in postprocedural assessment after transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI) from once at 10 years postop, to include at 30 days, at 1 year, and then annually, regardless of symptoms.
      • Expanded coverage of TTE in scenario of patient with suspected infective endocarditis (IE).
    • Added new 2022 CPT code 93319:
      • 3D echocardiographic imaging and post-processing during TTE or TEE, for congenital cardiac anomalies (List separately in addition to code for echocardiographic imaging).
Transthoracic Echocardiography in Children – (0523) Modified
  • Minor change in coverage criteria/policy:
    • No update to existing policy statement.
    • Added new 2022 CPT code 93319:
      • 3D echocardiographic imaging and post-processing during TTE or TEE, for congenital cardiac anomalies (List separately in addition to code for echocardiographic imaging).
Vitamin D Testing – (0526) Modified
  • Minor changes in coverage criteria/policy:
    • No change to policy statement section.
    • Removed vitamin D supplementation background information:
      • Scope is testing, not supplementation.
    • Updated ICD10 codes that are “frequency edit exceptions” to more accurately follow the Endocrine Society “Malabsorption syndromes” already listed, which includes:
      • Cystic fibrosis.
      • Inflammatory bowel disease.
      • Crohn's disease.
      • Bariatric surgery.
      • Radiation enteritis.
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • No updates for March 2022.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Comprehensive Musculoskeletal Management (CMM) guidelines Modified
  • Advance notification of important changes, posting March 28, 2022, effective July 1, 2022.
    • CMM 311 Knee Replacement Arthroplasty:
      • Added knee varus deformity of “> or = 10 degrees and coronal tibiofemoral subluxation of > or = 6 mm consistent with an anterior cruciate ligament (ACL) deficient osteoarthritic knee” criteria to partial knee.
    • CMM 312 Knee Surgery Arthroscopic and Open:
      • Added ACL repair as EIU.
      • Added clarification to medial patellofemoral ligament changes, which will expand coverage.
    • CMM 313 Hip Replacement Arthroplasty:
      • Editorial changes only.
    • CMM 314 Hip Surgery Arthroscopic and Open:
      • Editorial changes only.
    • CMM 315 Shoulder Surgery Arthroscopic and Open:
      • Separated criteria for labral and biceps tenodesis into two sections, no change to intent.
    • CMM 318 Shoulder Arthroplasty:
      • Added “Walch Classification” in definition section, used to define glenohumeral osteoarthritis and to assist with preoperative planning.
      • Changed Charcot arthropathy to Charcot joint, along with other editorial/formatting changes.
      • Added irreparable shoulder fracture as criteria under “Reverse Total Shoulder Arthroplasty” as well as “glenoid retroversion on imaging” using the Walch classification.
Gastrointestinal Endoscopic Procedures guidelines Modified
  • Important changes, posted November 26, 2021, effective March 1, 2022 include:
    • Capsule Endoscopy:
      • Editorial and formatting changes to improve clarity along with updating the section with general information related to guidelines and medical necessity review.
      • Changes in coverage:
        • Added new indication for capsule endoscopy:
          • The evaluation of Familial Adenomatous Polyposis (FAP), Attenuated Familial Adenomatous Polyposis (AFAP) Syndromes, and MUTYH-Associated Polyposis when criteria is met.
    • Esophagogastroduodenoscopy (EGD):
      • Editorial and formatting changes to improve clarity along with updating the section with general information related to guidelines and medical necessity review.
      • Changes in coverage:
        • Added coverage for a follow-up EGD for eosinophilic esophagitis when criteria is met.
        • Update requires a confirmed diagnosis of pernicious anemia to be eligible for EGD.
        • Lowered age for beginning EGD surveillance in classical familial polyposis (FAP)/attenuated FAP from 25 to age 20.
        • Added additional indication for EGD prior to 20 years of age with classical FAP/attenuated FAP, EGD is medically necessary when request is before a planned colectomy.
High-Tech Radiology (HTR or Imaging) guidelines Modified
  • Important changes, effective April 1, 2022:
    • Updated the General Cardiac Imaging guideline, which will expand coverage for some imaging procedures.
Policies Status Details
Administrative Policies
  • No updates for March 2022.
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Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective March 1, 2022:
Lorazepam Extended-Release – (IP0364) New
  • Supports pharmacy noncoverage for Loreev XR.
Tofacitinib - (IP0230) New
Delafloxacin – (IP0373)
  • Effective March 15, 2022.
  • Replaces Delafloxacin – (P0045).

Goserelin Acetate Subcutaneous Implant - (IP0353)

Lonapegsomatropin - (IP0375)
  • Effective March 15, 2022.

Metreleptin - (IP0340)

Oxazolidinone Antibiotics – (IP0372)
  • Effective March 15, 2022.
  • Supports pharmacy prior authorization of linezolid, Sivextro, and Zyvox.
  • Replaces Oxazolidinone Antibiotics – (1123).

Testosterone (Injectables and Implantable Pellets) – (IP0351)
  • Replaces Testosterone Therapy (Oral, Nasal, and Topical) – (2013).

Testosterone (Oral, Topical, and Nasal) – (IP0350)
  • Replaces Testosterone Therapy (Oral, Nasal, and Topical) – (2013).

Ustekinumab Subcutaneous - (IP0239)
New
  • Supports pharmacy prior authorization requirements.
Efgartigimod - (IP0376)

Hydroxyprogesterone Caproate Injection – (IP0370)
  • Effective March 15, 2022.
  • Replaces Hydroxyprogesterone Caproate Injection – (1108).

Inclisiran - (IP0380)

Plasminogen - (IP0382)

Protein C Concentrate - (IP0342)
  • Replaces Protein C Concentrate – (1604).

Rituximab for Non-Oncology Indications – (IP0319)
  • Replaces Rituximab for Non-Oncology Indications - (5108).

Triamcinolone Acetonide Ophthalmic - (IP0371)

Ustekinumab Intravenous - (IP0240)
New
  • Supports medical precertification requirements.
FEIBA – (IP0354)

Fibrinogen Products – (IP0357)
  • Supports medical necessity review of Fibryga and RiaSTAP.

NovoSeven RT – (IP0356)

Sevenfact – (IP0355)
New
Clotting Factors and Antithrombin – (8007) Modified
COVID-19 Drug and Biologic Therapeutics - (2016) Modified
  • Important changes in coverage criteria, effective February 15, 2022:
    • Added criteria for bebtelovimab consistent with Emergency Use Authorization (EUA) issued on February 11, 2022, for use as treatment of mild-to-moderate COVID-19 in certain adults and pediatric individuals.
Immune Globulin - (5026) Modified
  • Important changes in coverage criteria:
    • Added Cutaquig and Xembify as preferred products.
    • Updated Gammagard S/D nonpreferred product exception criteria.
    • Added Gammaplex to preferred product list for Gammagard Liquid.
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
Medication Administration Site of Care - (1605) Modified
  • Minor changes in coverage criteria/policy, effective March 15, 2022:
    • Added Apretude and Tezspire.
Migraine Treatment – (IP0029) Modified
  • Important changes in coverage criteria, effective March 15, 2022:
    • Added Trudhesa with medical necessity exception criteria.
    • Updated medical necessity exception criteria for dihydroergotamine and Migranal nasal sprays to require a step through Trudhesa in addition to sumatriptan nasal spray.
Pharmacy Prior Authorization – (1407) Modified
Routine Immunizations - (9001) Modified
  • Important changes in coverage criteria, effective July 1, 2022:
    • Added quantity limitation to Shingrix to 2 doses per 720 days.
Secukinumab - (IP0223) Modified
  • Important changes in coverage criteria, effective March 15, 2022:
    • Added age limitation to ankylosing spondylitis, non-radiograph-axial spondyloarthritis, and psoriatic arthritis.
    • Added nonsteroidal anti-inflammatory drug therapy as alternative for axial disease in psoriatic arthritis.
    • Removed three-month minimum duration trial of first-line therapy for plaque psoriasis.
    • Updated preferred product tables to include Xeljanz/XR for ankylosing spondylitis as a preferred alternative.
    • Updated preferred product tables to include Rinvoq for psoriatic arthritis as a preferred alternative.
Upadacitinib - (IP0229) Modified
  • Important changes in coverage criteria, effective March 15, 2022:
    • Added medical necessity criteria for:
      • Atopic dermatitis.
      • Psoriatic arthritis.
    • Updated medical necessity criteria for rheumatoid arthritis.
Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use – (1206) Modified
  • Minor changes in coverage criteria/policy:
    • Removed Macugen (pegaptanib sodium):
      • Product discontinued.
Delafloxacin – (P0045) Retired
Hydroxyprogesterone Caproate Injection – (1108) Retired
Oxazolidinone Antibiotics – (1123) Retired
Protein C Concentrate - (1604) Retired
Rituximab for Non-Oncology Indications - (5108) Retired
Testosterone Therapy (Injectables and Implantable Pellets) – (1503) Retired
Testosterone Therapy (Oral, Nasal, and Topicals) – (2013) Retired
Policies Status Details
Cigna National Formaulary (CNF) Coverage Policies
  • Cigna National Formulary (CNF) policies are located on the CNF Policies A-Z Index.
    • Policies are listed alphabetically by document title
      • Document titles include the policy type and may include the drug name, class, and/or condition
    • Policies can also be searched by a product identification (ID) number, which is a unique identifier to a specific product/policy.
      • When applicable, searching by product ID helps locate the corresponding CNF policy.
    • Details of updates to each CNF policy are located under the “Revision History” section.
  • More information about Cigna's drug lists can be found at Prescription Drug Lists and Coverage | Cigna
  • More information about Cigna's drug lists changes can be found at CHCP - Resources - Cigna's Prescription Drug Lists.
    • CNF formulary changes can be found in the Prescription Drug List Changes document under Cigna National Prescription Drug List, located at the bottom of the page.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for March 2022
Policies Status Details
Precertification List – Commercial (Non-Medicare) Business*
  • No updates for March 2022
Policies Status Details
Precertification List – Medicare Business*
  • No updates for March 2022
Policies Status Details
Reimbursement Policies*
Care Integration Services – (R32)
COVID-19 Interim Billing Guidelines – (R33)
Facility Routine Services, Supplies, and Equipment – (R12)
Omnibus Reimbursement Policy – (R24)
  • Policies were updated.
Policies Status Details
ClaimsXten*
  • No updates for March 2022

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.