Policy Updates May 2016

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective May15, 2016:
Bariatric Surgery - (0051) Modified
  • Important change in coverage:
    • Updated to note requirement of only one instead of two documents for multidisciplinary evaluation.
  • Policy statement updates with no change in coverage:
    • Added physician extender language throughout the weight management and multidisciplinary evaluation sections.
    • Added "stand-alone or staged procedure" to the sleeve gastrectomy bullet in the covered procedures section.
    • Added single anastomosis duodenal switch procedure to the not covered list.
    • Added a parenthetical with FDA-approved intragastric balloon devices in the not covered section.
    • Updated the reoperation and repeat bariatric surgery section to address the following:
      • Added new statements:
        • Replacement, separate or concurrent band removal and conversion for technical failure.
        • Lap band removal alone for a symptomatic band.
        • Surgical repair/reversal/conversion of any bariatric procedure due to major complications
      • Rearranged bullets in the revision or conversion section for better flow of criteria.
        • Added "unsuccessful band adjustments" to fourth bullet in the revision or conversion of any bariatric procedure due to inadequate weight loss section to clarify technical failure.
        • Added note after bullets for secondary surgery in the absence of complications or weight loss failure.
Bone Growth Stimulators: Electric (Invasive, Noninvasive) Ultrasound - (0084) Modified
  • Important change in coverage:
    • Added criteria for noninvasive spinal electrical bone growth stimulator as medically necessary for treatment of a failed lumbar fusion.
Cognitive Rehabilitation - (0124) Modified
  • Policy statement update with no change in coverage:
    • Incorporated content from Coma Stimulation CP 0272 (retired March 15, 2016).
Genetic Testing for Hereditary and Multifactorial Conditions - (0052) Modified
  • Updates are not effective until August 15, 2016.
  • This will provide advance health care professional notification.
    • Both versions will be available on the CignaforHCP.com site until August 15, 2016; one current and one with the August 15, 2016 effective date.
  • The current version should be used for all determinations before August 15, 2016.
  • Important change in coverage:
    • Added coverage criteria for factor V Leiden and factor II prothrombin genetic testing.
      • Criteria were not previously in the coverage policy.
      • Criteria are more restrictive than the criteria that were in the Genetic Testing for Hereditary Hypercoagulability Disorders CP0255 (retired March 15, 2016).
Genetic Testing for Reproductive Carrier Screening and Prenatal Diagnosis - (0514) Modified
  • Updates are not effective until August 15, 2016.
  • This will provide advance health care professional notification.
    • Both versions will be available on the CignaforHCP.com site until August 15, 2016; one current and one with the August 15, 2016 effective date.
  • The current version should be used for all determinations before August 15, 2016.
  • Important changes in coverage:
    • Updated coverage for genetic testing for factor V Leiden and factor II prothrombin thrombophilia in recurrent pregnancy loss section.
    • Removed requirement that genetic disorder be completely penetrant and associated with severe disability.
    • Limited treatment options for invasive prenatal testing of a fetus.
  • Policy statement update with no change in coverage:
    • Removed the redundant term "high-risk" from the non-invasive prenatal testing policy statement.
      • Indications in the covered policy statement are all high risk.
Hearing Aids - (0093) Modified
  • Policy statement updates with no change in coverage:
    • Added "device" to all occurrences of "hearing aid."
    • Added "used to amplify sound" to the lead coverage statement.
    • Added "absence of middle ear disease" to criteria for semi-implantable middle ear hearing aid device.
    • Removed "all but the most severe" from the bullet for in the ear canal (ITC) device and substituted/added the reverse, "mild to moderate" hearing loss.
    • Added parenthetical with device names to the semi-implantable middle ear hearing aid section.
    • Added "(decibel hearing level) with average measured at 500, 1000, 2000, and 3000 Hz" to unilateral and bilateral percutaneous bone-anchored hearing aid (BAHA) sections.
    • Added "> 100 dBHL" to the unilateral percutaneous BAHA as an alternative to contralateral routing of sound (CROS) section to reflect single-sided deafness.
    • Other editorial additions/changes including the correction of device names.
Phototherapy, Photochemotherapy, and Excimer Laser Therapy for Dermatologic Conditions - (0031) Modified
  • Policy statement update with no change in coverage:
    • Organized policy statement by adding new subheader "Excimer Laser Therapy".
      • Moved information from the bottom of the statement in the "Not Covered" section up into the appropriate subheader, "Office-Based Phototherapy and Photochemotherapy" and "Excimer Laser Therapy."
Seat Lift Mechanisms, Patient Lifts and Standing Devices - (0343) Modified
  • Policy statement updates with no change in coverage:
    • Removed "devices" and added "frame/table systems" to the third bullet in the non-covered section to more closely align with the HCPCS code description.
Strapping and Taping - (0512) Modified
  • Changes below were previously posted on February 15, 2016 to provide advance health care professional notification.
  • Changes are now effective starting May 15, 2016.
  • The previous version of the policy will be removed May 15, 2016.
  • Important changes in coverage:
    • Strapping codes were being allowed without review.
      • New procedure to diagnosis (PXDX) edits will allow some strapping codes for specific diagnoses; while others will not be allowed for any diagnosis.
    • Elastic therapeutic tape/taping (e.g., Kinesio™ tape, KT TAPE/KT TAPE PRO™, Spidertech™ tape) is not allowed for any indication.
      • Information already in Physical Therapy - (0096).
      • No specific CPT code for elastic therapeutic taping
      • Often billed with strapping codes.
Tumor Profiling, Gene Expression Assays and Molecular Diagnostic Testing for Hematology/Oncology Indications - (0520) Modified
  • Important change in coverage:
    • Added coverage for Prosigna Breast Cancer Assay (PAM50), previously addressed in Genetic Testing Collateral File as experimental, investigational, and unproven (EIU).
  • Unknown if change in coverage (not previously addressed in any coverage policy):
    • Added coverage for the following prostate profiling tests:
      • 4Kscore
      • ConfirmMDX
      • percent free PSA
      • Prostate Health Index (PHI)
      • Progensa® PCA3 Assay
  • Policy statement update with no change in coverage:
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective May 15, 2016:
Protein C Concentrate - Human (Ceprotin®) - (1604) New
  • Policy supports medical precertification with diagnostic criteria.
Brand Name Drugs 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:
    • Added authorized generics for Nesina, Kazano, and Oseni.
Brand Name Drugs 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:
    • Added authorized generics for Nesina, Kazano, and Oseni.
Compounded Medications - (1406) Modified
  • Important changes in coverage:
    • Added that compounded naltrexone implants are not covered
      • Products are not FDA approved.
    • Updated list of medications not approved by the FDA for topical use that are not covered when compounded for topical use in the section for not covered compounds that are EIU.
Hereditary Angioedema (HAE) Therapy - (1019) Modified
  • Important changes in coverage:
    • Removed age-specific criteria restrictions from all products.
    • Added criteria requiring evaluation of medications that may precipitate HAE for all products.
    • Added criteria requiring a second C4 level to confirm diagnosis for all products
    • Added "or antifibrinolytics" to prior therapies for HAE prophylaxis for Cinryze (C1 esterase inhibitor [human]) criteria,
    • Removed diagnostic criteria stating "known HAE causing C1INH mutation" for Cinryze.
Idiopathic Pulmonary Fibrosis Therapy - (1505) Modified
  • Important changes in coverage:
    • Removed pulmonary function testing requirement of a forced vital capacity (FVC) of at least 50 percent.
Implantable Hormone Pellets - (1504) Modified
  • Policy statement update with no change in coverage:
    • Added standard dose management statement.
Infertility Injectables - (1012) Modified
  • Important changes in coverage:
    • Added "documented" to primary or secondary hypogonadotropic hypogonadism under Human Chorionic Gonadotropin (hCG).
Multiple Sclerosis Therapy - (1402) Modified
  • Important changes in coverage:
    • Added standard sampling statement (receipt of samples does not satisfy criteria requirements for coverage).
    • Updated all intolerance language to documented intolerance.
    • Updated all contraindication language to contraindication per FDA label.
    • Expanded coverage criteria for Aubagio®, Betaseron®, Extavia®, Gilenya®, Lemtrada®, and Plegridy® by adding "not a candidate (e.g., stabilized condition where therapeutic interchange is inappropriate") to allow for continuation of therapy.
      • Betaseron will continue to require inability to use Extavia.
    • Expanded coverage of Tysabri for individuals "not a candidate" for alternate disease modifying therapy.
Oncology Medications - (1403)) Modified
  • Important changes in coverage:
    • Added newly FDA approved oncology medication requiring pharmacy prior authorization for venetoclax (Venclexta™).
Step Therapy - (1109) Modified
  • Important changes in coverage:
    • Updated to align with implemented program for Global Step Therapy.
    • Under ACEI/ARB (Antihypertensive ACE-Inhibitors/Angiotensin Receptor Blockers):
      • Step 1 - Added candesartan (generic Atacand).
      • Step 3 - Removed Monopril, Monopril HCT, Teveten®, Teveten HCT (not available).
    • Under ADHD (Attention Deficit Hyperactive Disorder):
      • Step 3 - Added Ritalin LA® 60mg.
    • Under Atypical Antipsychotic Agents:
      • Step 1 - Removed aripiprazole (generic Abilify®).
    • Under Bone Resorption Inhibitors:
      • Step 1 - Removed 150mg strength from risedronate.
      • Step 3 - Removed Skelid (not available).
    • Under Urinary Tract Antispasmodic Agents:
      • Step 1 - Added darifenacin ER (generic Enablex).
    • Under SSRI/SNRI (Serotonin Selective/Serotonin Norepinephrine Receptor Inhibitor):
      • Step 3 - Added Brintellix® and Irenka (brand of duloxetine).
    • Under Topical Immunomodulators:
      • Step 3 - Added Clodan® (brand clobetasol) and removed Carmol HC.
Policies Status Details
Administrative Policies
There were no administrative policy updates for May.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Fifteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
Policies Status Details
Reimbursement Policies*
All changes are effective on May 16, 2016:
R25 Drug Testing Billing Requirements Modified
  • Important changes:
    • Participating health care professionals must bill new 2016 CMS codes for presumptive and definitive drug testing and follow billing guidelines for the new codes described in the policy.
    • CPT codes for presumptive and definitive testing will not be accepted.
R24 Omnibus Reimbursement Policy Modified
  • Important changes:
    • Drug kits will not be reimbursed.
      • All drugs should be billed separately.
      • Supplies are not eligible for separate reimbursement.
R08 Unlisted Codes Modified
  • Important changes:
    • All items within drug kits must be billed separately with appropriate specific codes for each item.
    • Coding table removed.
Policies Status Details
Claim Editing Policies and Procedures ClaimsXten
On May 14, 2016, ClaimsXten will be updated to Second Quarter Knowledge Base content and NCCI Version 22.1 for all medical and behavioral claims.
Policies Status Details
Policies with a Reduction in Coverage**
Drug Convenience Kits Modified Separate reimbursement for drug convenience kits will be denied because they include supplies considered incidental to the primary service of providing the drug. Only the drug(s) should be billed.
Drug Testing Billing Requirements (R25) Modified Claims with outdated G-codes and CPT® codes for definitive drug testing will be denied. We will only reimburse claims submitted with the new Centers for Medicare & Medicaid Services (CMS) G-codes.
Strapping and Taping (0512)
Physical Therapy (0096)
Modified We will create a new strapping and taping coverage policy and update the current physical therapy coverage policy to identify medical conditions or areas of the body where strapping is considered medically necessary.
Taping is considered experimental, investigational, or unproven (EIU) for all diagnoses. Strapping services that are billed with CPT codes for any medical conditions or body areas not specified in the coverage policies will be denied as not medically necessary or EIU.

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.

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**The following policy updates, effective May 16, 2016, will result in a reduction of coverage.