Policy Updates May 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective May 15, 2017:
Hearing Aids – (0093) Modified
  • Important changes in coverage criteria:
    • Added coverage for partially implantable magnetic bone conduction hearing aid
      • e.g., Sophono® Alpha 2 System, Cochlear BAHA® 4 Attract.
    • Updated decibel hearing level (dB HL) requirements to align with U.S. Food and Drug Administration (FDA) approval criteria for BAHA devices.
    • Added coverage statement for batteries.
Transthoracic Echocardiography in Children – (0523) New
  • Advance notification of new policy effective August 19, 2017:
    • Supports initial outpatient non-stress transthoracic echocardiography (TTE) in an individual age 17 years or younger.
      • Does not address serial or subsequent TTE.
      • Does not address stress TTE.
      • Addresses outpatient hospitals off-campus (POS 19), outpatient hospitals on-campus (POS 22), and provider’s office (POS 11).
Breath Test for Detection of Heart Transplantation Rejection – (0456) Retired
Inert Gas Rebreathing for Cardiac Output Measurement – (0455) Retired
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy (drugs & biologics) coverage policies were modified effective May 15, 2017:
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 medical necessity criteria for Bevespi Aerosphere, Utibron Neohaler®, and ZonaCort.
    • Removed medical necessity criteria for Incruse® Ellipta®; which:
      • was added as a preferred brand.
      • is an alternative for Seebri Neohaler and Tudorza® Pressair®.
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 medical necessity criteria for Bevespi Aerosphere, Utibron Neohaler®, and ZonaCort.
    • Removed medical necessity criteria for Incruse® Ellipta®; which:
      • was added as a preferred brand.
      • is an alternative for Seebri Neohaler and Tudorza® Pressair®.
Hereditary Angioedema (HAE) Therapy - (1019) Modified
  • Important changes in coverage criteria:
    • Added option for genetic testing criteria for individuals who have normal laboratory levels and experience hereditary angioedema (HAE) attacks.
    • Added criteria not allowing concomitant use of HAE agents:
      • Exception is Cinryze, which is only used for prophylaxis, not treatment of attacks.
Idiopathic Pulmonary Fibrosis Therapy - (1505) Modified
  • Important changes in coverage criteria:
    • Removed specialist prescriber requirement.
    • Added option for patients with surgical lung biopsy that biopsy pattern alone is diagnostic of idiopathic pulmonary fibrosis (IPF).
Mecasermin – (6107) Modified
  • Important change in coverage criteria:
    • Removed that use in active or suspected neoplasia is experimental, investigational, or unproven (EIU).
      • Active or suspected neoplasia is a contraindication.
Multiple Sclerosis Therapy - (1402) Modified
  • Important change in coverage criteria:
    • Added Zinbryta® (daclizumab) criteria consistent with interim criteria approach.
Oncology Medications - (1403) Modified
  • Important change in coverage criteria:
    • Added Kineret (anakinra) and Bavencio (avelumab).
Quanity Limitations - (1201) Modified
  • Important changes in coverage criteria:
    • Added allowance for additional quantities of isotretinoin products to achieve a maximum cumulative weight-based dose.
    • Removed the Long Acting Narcotics therapeutic category.
    • Removed all controlled substances from the Pain Control therapeutic category.
      • Products removed from both categories were added to Controlled Substance Analgesics and Narcotic Antagonist Quantity Limitations - (1706).
    • Added a Headache Combinations therapeutic category.
Step Therapy - (1109) Modified
  • Important changes in coverage criteria:
    • Changes made to step therapy classes and emerging step therapy for:
      • Attention Deficit Hyperactive Disorder (ADHD)
      • Respiratory Medications
      • Selective Serotonin/Serotonin Norepinephrine Reuptake Inhibitor (SSRI / SNRI).
Controlled Substance Analgesics and Narcotic Antagonist Quantity Limitations - (1706) New
  • Supports quantity limitations on opioids and other controlled substances and narcotic antagonists that will take effect July 1, 2017.
  • Also contains other quantity limits (such as long-acting opioids) currently in effect.
Eteplirsen – (1702) New
  • Policy supports medical precertification.
Nusinersen – (1707) New
  • Policy supports medical precertification.
Policies Status Details
Administrative Policies
No updates for May 2017
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Unless otherwise noted, the following Cigna - eviCore CoBranded Guidelines were modified effective May 15, 2017:
Knee Surgery Arthroscopic and Open - (CMM 312) Modified
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Eleven policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
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Policies Status Details
Precertification Policies*
No updates for May 2017
Policies Status Details
Reimbursement Policies*
Updates have been made to the following:
R12 Facility Routine Services, Supplies and Equipment Modified
R15 Respiratory Services and Supplies Modified
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
Updates have been made to the following:
Code Edit and Policy Guidelines Modified
Policies Status Details
Policies with a Reduction in Coverage
There were no additional changes made in May 2017 that resulted in a reduction in coverage.

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.