Policy Updates May 2018

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 Status Update to Coverage
Policies with a Reduction in Coverage
We are changing how we reimburse for the following policies for claims on or after May 19, 2018.

*Facility Routine Services, Supplies and Equipment (R12)

*Pharmacy and Infusion Services (R14)

  • We will update two reimbursement policies and deny claims billed with CPT codes 96360-96379 and 96521-96523 when done in an outpatient setting and billed with a primary service code. This update is effective for claims processed on or after May 19, 2018.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective May 15, 2018:
Laser Interstitial Thermal Therapy - (0528) New
  • Advance notification of policy effective August 15, 2018.
  • Addresses laser interstitial thermal therapy (LITT), including magnetic resonance-guided laser interstitial thermal therapy (MRgLITT).
    • Adding new not covered policy statement.
    • CPT codes 19499, 27599, 32999, 55899, and 64999 already on precert.
Cognitive Rehabilitation – (0124) Modified
  • Important changes in coverage criteria:
    • Added policy statements for:
      • Cognitive rehabilitation in residential treatment center.
      • Continuation of cognitive rehabilitation.
        • No change in coverage.
Mechanical Devices for the Treatment of Back Pain – (0140) Modified
Negative Pressure Wound Therapy/Vacuum-Assisted Closure (VAC) for Non-Healing Wounds - (0064) Modified
  • Important change in coverage criteria:
    • Updated not covered policy statement re: battery-powered disposable negative pressure wound therapy (NPWT) devices.
      • No change in coverage.
Phototherapy, Photochemotherapy, and Excimer Laser Therapy for Dermatologic Conditions – (0031) Modified
  • Important changes in coverage criteria:
    • Added three new conditions to the existing not covered policy statement:
      • Cicatricial alopecia.
      • Diabetic foot ulcer.
      • Psoriatic nail disease.
        • No change in coverage.
Home Traction Devices: Cervical and Lumbar – (0265) Retired
Low-Level Laser Therapy – (0115) Retired
Acupuncture – (0024) Retired
  • Added content to new cobranded Cigna-American Specialty Health (ASH) Clinical Practice Guidelines (CPG) Acupuncture – (CPG 024)
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Unless otherwise noted, the following medical coverage policies were modified effective May 15, 2018:
Low-Level Laser and High-Power Laser Therapy - (CPG 030) New
  • Added policy statement for high-power laser therapy.
  • Clarified intent; no change in coverage.
  • Retired medical coverage policy Low-Level Laser Therapy – (0115)
Home Traction Devices – Cervical and Lumbar - (CPG 265) New
  • Clarified intent; no change in coverage.
  • Retired medical coverage policy Home Traction Devices: Cervical and Lumbar – (0265)
Axial/Spinal Decompression Therapy/Mechanical Traction (Provided in a Clinic Setting) – (CPG 275) New
  • Clarified intent; no change in coverage.
  • Removed references to VAX-D (including CPT/HCPCS codes S9090, 64722 and 97012) from Mechanical Devices for the Treatment of Back Pain – (0140).
Acupuncture – (CPG 024) New
  • Added coverage for musculoskeletal joint and soft tissue injury.
  • Retired medical coverage policy Acupuncture – (0024).
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Policies Status Details
Administrative Policies
  • No updates for May 2018.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective May 15, 2018:
Triamcinolone Acetonide Extended-Release Injection (Zilretta) – (1811) New
  • Supports medical precertification.
  • Supports enforcement of least costly alternative medical necessity definition.
Voretigene neparvovec – (1809) New
  • Supports medical precertification.
Afrezza - (1506) Modified
  • Important changes in coverage criteria:
    • Added “documented intolerance to, adverse effect from, or not a candidate for” to capture non-inability scenarios (lipohypertrophy).
    • Added visual impairment as inability example.
    • Removed “preferred” product language and formulary preference table.
Canakinumab - (1110) and Compounded Medications - (1406) Modified
  • Important changes in coverage criteria:
    • Added the following to list of experimental, investigational and unproven (EIU) conditions:
      • Adult Onset Still’s disease.
      • Behçet's disease.
      • Cardiovascular risk reduction and disorder prevention.
      • Majeed Syndrome.
      • Schnitzler Syndrome.
Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List - (1601) and 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 criteria for:
      • Toujeo Max Solostar.
      • Vyzulta.
      • Zypitamag.
Edaravone - (1806) Modified
  • Important changes in coverage criteria:
    • Updated reauthorization criteria to include requirements more specific than a clinical response.
Eteplirsen - (1702) Modified
  • Important change in coverage criteria:
    • Removed the requirement to continue to be able to walk 200 meters from reauthorization criteria.
Multiple Sclerosis Therapy - (1402) Modified
  • Important changes in coverage criteria:
    • Updated list of preferred alternatives for Betaseron and Extavia:
      • Added Tecfidera® and Copaxone.
      • Affects Individual and Family Plans only.
      • Aligns criteria statement with preferred product list.
Oxazolidinone Antibiotics - (1123) Modified
  • Important change in coverage criteria:
    • Added criteria for Zyvox for treatment of nontuberculous atypical mycobacterial infections.
Pharmacy Prior Authorization - (1407) Modified
  • Important changes in coverage criteria:
    • Revised Relistor criteria to align with labeled indications.
    • Added Toujeo Max Solostar criteria.
    • Removed “CHF” from the Entresto® criteria.
Step Therapy – (1109) Modified
  • Important changes in coverage criteria:
    • Removed additional criteria for Selective Serotonin/Serotonin Norepinephrine Reuptake Inhibitor (SSRI/SNRI) limiting to depression diagnosis only.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for May 2018.
Policies Status Details
Precertification Policies*
  • No updates for May 2018.
Policies Status Details
Reimbursement Policies*
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
  • No updates for May 2018.

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.