Policy Updates May 2019

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 policy:

Infusion and Injection Administration Services

*Facility Routine Services, Supplies and Equipment (R12)

*Pharmacy and Infusion Services (R14)

  • We will no longer separately reimburse infusion and injection administration services billed by facilities because infusion and injection administration services are considered incidental to the primary service and are not separately reimbursable.
  • The affected Current Procedural Terminology (CPT®) codes are 96360 through 96379, and 96521 through 96523.
  • This update is effective for claims processed beginning May 18, 2019.

Modifier 90 Pass-Through Billing

*Laboratory Services (R17)

  • We will deny bills for pass-through laboratory services. These are lab services submitted with modifier 90 in place of service (POS) 11 (office setting).
  • This update is effective for claims processed beginning May 18, 2019.

Flow Cytometry (0538)

  • We will implement a new medical coverage policy, Flow Cytometry (0537), to review tests for medical necessity.
  • The affected Current Procedural Terminology (CPT®) codes include 86355, 86356, 86357, 86359, 86360, 86361, 86367, 88182, 88184, 88185, 88187, 88188, and 88189
  • This update is effective for claims processed beginning May 20, 2019.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective May 15, 2019:
Duplex Scan to Evaluate for Carotid Artery Stenosis – (0542) New
  • Advance notification of policy posting May 18, 2019; effective July 15, 2019
    • Identifies indications for which duplex scan is considered medically necessary in the evaluation of carotid artery stenosis.
Orthotic Devices and Shoes – (0543) New
  • Advance notification of policy effective August 15, 2019.
    • Combines information from five existing policies, which will be retired in August:
      • Cranial Orthotic Devices for Positional or Deformational Plagiocephaly – (0056)
      • Knee Braces - (0362)
      • Lower Limb Orthotics and Shoes - (0150)
      • Myoelectric Devices: Upper Limb - (0233)
      • Spinal Orthoses - (0394)
    • Added new policy statement with medical necessity criteria for upper limb orthotic devices.
    • New edit will deny upper limb, lower limb, knee braces and spinal orthosis when there is no physical exam
Venous Angioplasty With or Without Stent Placement for Adults – (0541) New
  • Advance notification of policy posting May 23, 2019, effective August 23, 2019:
    • Will be managed via precertification.
    • Not previously managed.

Allergy Testing and Non-Pharmacologic Treatment - (0070)

Modified
  • Important changes in coverage criteria:
    • Removed alpha gal testing from experimental, investigational or unproven (EIU) policy statement.
    • Revised frequency for immunotherapy to rolling twelve months.
    • Added statement referring users to Sublingual Allergen Immunotherapy – (1902) for information about FDA-approved sublingual immunotherapy.
Cervical Fusion - (0527) and Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, Including Sacroiliac Fusion - (0303) Modified
  • Advance notification of important changes in coverage criteria, effective August 15, 2019:
    • Adding “add on” codes to coding tables and to precertification.
      • Will be denied when primary fusion procedure is denied.
Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery – (0481) Modified
  • Advance notification of important changes in coverage criteria, effective August 15, 2019:
    • Implementing existing EIU policy statement related to sinus diagnosis.
Genetic Testing for Reproductive Carrier Testing and Prenatal Diagnosis - (0514) Modified
  • Advance notification of important changes in coverage criteria, effective August 15, 2019:
    • Implementing existing policy statements related to non-invasive prenatal testing (NIPT).
Hyperbaric and Topical Oxygen Therapies – (0053) Modified
  • Minor change in coverage criteria/policy:
    • Changed title from “Hyperbaric Oxygen Therapy, Systemic and Topical”.
      • No change in coverage.
Injectable Fillers - (0511) Modified
  • Important changes in coverage criteria:
    • Added policy statement for FDA-approved injectable fillers for the treatment of facial lipodystrophy syndrome caused by antiretroviral therapy in HIV-infected persons.
    • Changed wording in policy statement from cosmetic services to not medically necessary and removed disclaimer information.
      • No change in coverage.
Omnibus Codes - (0504) Modified
  • Important changes in coverage criteria:
    • Added policy statement for transperineal placement of biodegradable material, periprostatic, single or multiple injections.
    • Updated policy statement for fecal calprotectin from not covered to include coverage for a subset of individuals.
    • Added rectal control system for vaginal insertion as EIU.
    • Added procedures removed from this policy to Peripheral Nerve Stimulation and Peripheral Nerve Field Stimulation – (0539):
      • Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve).
      • Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous.
Seat Lift Mechanisms, Patient Lifts and Standing Devices - (0343) Modified
  • Important changes in coverage criteria:
    • Revised existing policy statement to cover other types of patient lifts (electrical, mechanical, and hydraulic):
      • Patient lift, electric, with seat or sling.
      • Multipositional patient support system, with integrated lift, patient accessible controls.
      • Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories.
    • Added policy statement for a new combination transfer and mobility device.
Vitamin D Testing - (0526) Modified
  • Advance notification of important changes in coverage criteria, effective August 19, 2019:
    • Added new frequency not medically necessary (NMN) edit.
      • Deny 82306 if 3 or more tests in 12 rolling months for the same member.
      • Exceptions include chronic kidney disease (CKD) or intestinal malabsorption.
    • Added new duplicate NMN edit.
      • Deny 82652 if billed with 82306 for the same member on the same date of service, regardless of provider.
    • New edits apply to all ages.
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • No new or updated policies for May 2019.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Advance notification of updates to the following Cigna-eviCore Cobranded Comprehensive Musculoskeletal Management (CMM) guideline, effective August 15, 2019: Modified
  • Knee Surgery Arthroscopic and Open - (CMM 312):
    • Added new policy statement addressing hybrid autologous chondrocyte implantation
Advance notification of updates to the following Cigna-eviCore Cobranded High-Tech Radiology (HTR or Imaging) guidelines, posted May 1, 2019, effective August 1, 2019: Modified
  • Adult Abdomen
  • Pediatric Abdomen
  • Adult Cardiac
  • Adult Musculoskeletal
  • Adult Spine
  • Adult Peripheral Vascular Disease (PVD)
Policies Status Details
Administrative Policies
  • No updates for May 2019.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective May 1, 2019:
Abatacept Intravenous (Employer Group Benefit Plans) - (M0006) New
  • Lists criteria for abatacept intravenous (Orencia) separately.
Abilify Mycite – (P0086) New
  • Supports noncoverage of Abilify Mycite.
Burosumab-twza – (M0002) New
Clobazam Oral Film – (P0085) New
  • Supports pharmacy prior authorization of Sympazan (clobazam oral film).
Golimumab Intravenous (Employer Group Benefit Plans) - (M0007) New
  • Lists criteria for golimumab intravenous (Simponi Aria) separately.
Immunomodulators (Individual and Family Plans) - (1903) New
  • Lists criteria for all immunomodulators for individual and family plans separately.
Infliximab (Employer Group Benefit Plans) - (M0003) New
  • Lists criteria for infliximab intravenous (Remicade, Inflectra, and Renflexis) separately.
Natalizumab for Crohn's Disease (Employer Group Benefit Plans) - (M0008) New
  • Lists criteria for intravenous natalizumab (Tysabri) for Crohn’s disease separately.
Ophthalmic Prostaglandin Analogs - (P0088) New
  • Supports pharmacy coverage review of ophthalmic prostaglandin analogs.
Tocilizumab Intravenous (Employer Group Benefit Plans) - (M0004) New
  • Lists criteria for intravenous tocilizumab separately.
Vedolizumab (Employer Group Benefit Plans) - (M0005) New
  • Lists criteria for intravenous vedolizumab separately.
Antiemetic Therapy – (1705) Modified
  • Minor changes in coverage criteria/policy:
    • Added product discontinuation statement to coverage criteria stem for Varubi IV due to suspended distribution beginning March 14, 2018 secondary safety information reported.
    • Updated medical coding due to updates retroactive for January 1, 2019:
      • Added J0185 Injection, aprepitant, 1 mg.
      • Added J1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg.
Cholic acid - (P0009) Modified
  • Important changes in coverage criteria:
    • Added initial authorization period of up to three months:
      • Supported by FDA label: Discontinue treatment with Cholbam if liver function does not improve within three months of the start of treatment or complete biliary obstruction develops.
    • Added specific reauthorization criteria:
      • Supported by FDA label: Discontinue treatment with Cholbam if liver function does not improve within three months of the start of treatment or complete biliary obstruction develops.
    • Added EIU specific uses:
      • Supported by FDA label: Limitation of use: The safety and effectiveness of Cholbam on extrahepatic manifestations of bile acid synthesis disorders due to SEDs or PDs including Zellweger spectrum disorders have not been established.
Dose Optimization - (1804) Modified
  • Minor changes in coverage criteria:
    • Added Qmiiz ODT 7.5mg tablet to the dose optimization program under Pain Relief and Inflammatory Disease.
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
  • Minor changes in coverage criteria:
    • Added medical necessity criteria for Dxevo and Tolsura.
    • Updated criteria for Trulance to include Motegrity:
      • Added as a covered alternative.
    • Added criteria for the authorized generic of Humalog (insulin lispro) for Standard/Performance Prescription Drug Lists only.
Dupilumab - (1810) Modified
  • Minor changes in coverage criteria:
    • Extended coverage of Dupixent for atopic dermatitis from adults only to 12 years and older following FDA indication expansion.
Idiopathic Pulmonary Fibrosis - (1505) Modified
  • Important changes in coverage criteria:
    • Reworded stem bullets to mirror guideline language from the Diagnosis of Idiopathic Pulmonary Fibrosis: An Official American Thoracic Society (ATS), European Respiratory Society (ERS), Japanese Respiratory Society (JRS), AND Latin American Thoracic Society Clinical Practice Guideline for Idiopathic Pulmonary Fibrosis.
    • Added the requirement of serological testing to align with ATS/ERS/ALAT 2018 guidelines.
    • Reworded the bullet about high resolution computer tomography and lung biopsy to align with 2018 ATS/ERS/ALAT guideline recommendations; provided high resolution computer tomography pattern which are required (subpleural and basal predominant distribution and honeycombing).
    • Added authorization and reauthorization duration of 12 months and for continued use the individual must met the initial criteria for use.
Immunomodulators - Oral and Subcutaneous (Employer Group Benefit Plans) - (1805) Modified
Isavuconazonium - (P0011) Modified
  • Important change in coverage criteria:
    • Added statement clarifying the policy addresses the use of oral isavuconazonium, and that IV formulation is not addressed by policy.
    • Removed age requirement limiting the use of isavuconazonium to individuals 18 years and older for both aspergillosis and mucormycosis uses.
    • Added criterion for documented failure, contraindication, intolerance, or not a candidate for fluconazole for treatment of invasive candidiasis/candidemia consistent with Infectious Diseases Society of America (IDSA) guideline recommendations for its use as an initial alternative therapy in select individuals.
    • Added reauthorization language statement to clarify continuation of use is contingent on initial authorization criteria continuing to be met:
      • No change to how policy is currently implemented.
    • Added initial authorization and reauthorization intervals:
      • No change to how policy is currently implemented.
    • Added EIU use statement:
      • No change to how policy is currently implemented.
Medication Administration Site of Care - (1605) Modified
  • Minor changes in coverage criteria:
    • Removed HCPCS code J3315 - triptorelin pamoate, 3.75 mg from medical precertification table.
Multiple Sclerosis Therapy - (1402) Modified
  • Minor changes in coverage criteria:
    • Added Ocrevus as preferred product.
    • Removed Zinbryta:
      • Product withdrawn from the market in April 2018.
    • Added initial and reauthorization criteria.
Naloxone - (P0017) Modified
  • Minor change in coverage criteria:
    • Added initial and reauthorization criteria.
Nebulized Solutions for COPD - (P0053) Modified
  • Minor changes in coverage criteria:
    • Updated title from Glycopyrrolate to Nebulized Solutions for COPD.
    • Added Yupelri to coverage criteria.
Oncology Medications - (1403) Modified
  • Minor changes in coverage criteria:
    • Added specific additional criteria requiring a step therapy requirement for either Ibrance or Verzenio first as responsive to a business decision effective July 1, 2019 for the cyclin-dependent kinase (CDK) inhibitors and as clarified to include Kisqali Femara Co-pack.
    • Added Elzonris (tagraxofusp-erzs), Infugem (gemcitabine) and Herceptin Hycleta (trastuzumab-oysk) to medical precertification table.
Pyrimethamine - (P0012) Modified
  • Important changes in coverage criteria:
    • Revised coverage criteria language for toxoplasmosis and pneumocystis pneumonia (PCP) in HIV-infected individuals removing the language failure (to trimethoprim-sulfamethoxazole [TMP-SMX]) consistent with Department of Health and Human Services (DHHS) recommendation that alternative treatments be reserved for individuals with sulfa intolerance:
      • No change to intent of language.
    • Revised coverage criteria language for isosporiasis in HIV-infected individuals:
      • No change to intent of language.
    • Removed coverage criteria for treatment and prophylaxis of malaria because uses are no longer recommended in compendia and guidelines.
    • Added reauthorization language statement to clarify continuation of use is contingent on initial authorization criteria continuing to be met:
      • No change to how policy is currently implemented.
    • Added initial authorization and reauthorization intervals:
      • No change to how policy is currently implemented.
Quantity Limitations - (1201) Modified
  • Minor changes in coverage criteria:
    • Added quantity limits for:
      • Aemcolo
      • Firdapse
      • Tuxarin ER
      • Xyosted
Rilonacept - (P0007) Modified
  • Minor changes in coverage criteria:
    • Added re-authorization criteria for continued use (documentation of positive clinical response)
    • Added specific re-authorization time period of up to 12 months.
    • Added six additional uses not covered (EIU):
      • Adult onset Still’s disease
      • Gout
      • Gouty arthritis
      • Juvenile idiopathic arthritis
      • Schnitzler syndrome
      • Type 1 Diabetes Mellitus
Somatropin - (4012) Modified
  • Minor changes in coverage criteria:
    • Added Norditropin as preferred for employer group plans; therefore added Norditropin as an additional requirement for:
      • Genotropin
      • Nutropin
      • Nutropin AQ
      • Omnitrope
      • Saizen
      • Zomacton
    • Corrected entry for Silver–Russell Syndrome unless they meet criteria for Small for Gestational Age in EIU use section.
Step Therapy - (1109) Modified
  • Minor changes in coverage criteria:
    • Added Qmiiz ODT as an NSAID class target and Bryhali as a topical inflammatory/very high potency class target.
    • Moved Advair Diskus from an alternative to a step target for respiratory classes.
      • Added the authorized generic for Advair Diskus and the A-rated generic (Wixela Inhub) as alternatives.
    • Added Motegrity as an alternative for Trulance.
Step Therapy - (1801) and Step Therapy – (1802) and Step Therapy – (1803) Modified
  • Minor changes in coverage criteria:
    • Added Qmiiz ODT as an NSAID class target and Bryhali as a topical inflammatory/very high potency class target.
    • Removed Advair Diskus as an alternative for the Trelegy Ellipta.
      • Added the authorized generic for Advair Diskus and the A-rated generic (Wixela Inhub) as alternatives and Advair HFA specified.
    • For Legacy Prescription Drug Lists - Step Therapy – (1803) only:
      • Corrected that Lialda is a target and not an alternative for the 5-Aminosalicylates (5-ASAs) class.
      • Added Motegrity as an alternative for Trulance.
    • Advair Diskus added as a target for respiratory class, Asthma combination.
Testosterone Therapy - (1503) Modified
  • Minor changes in coverage criteria:
    • Added Xyosted.
Transmucosal Fentanyl - (1018) Modified
  • Minor changes in coverage criteria:
    • Added initial and reauthorization criteria.
Unassigned Drug or Biologic Code Medical Precertification - (1701) Modified
Policies Status Details
CareAllies Medical Necessity Guidelines
  • Two policies updated for May 2019.
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
Code Editing Policy & Guidelines
  • Advance notification of important changes effective July 15, 2019:
    • To better align with CMS, Cigna is implementing Medically Unlikely Edits (MUE) for CPT codes 97010, 97026, 97032–97036, 97110–97124, 97140, 97150, 97530 and 97542.
    • The MUE rules apply frequency limitations as defined by CMS based on anatomic considerations, HCPCS or CPT code descriptors, CPT instructions, CMS policies, the nature of service or procedure, and clinical feasibility.
    • Services billed in excess of the MUE frequency limitations will be administratively denied and appeal rights will be afforded.
Code Edit Bulletin (July 2019)
  • Advance notification of important changes effective July 15, 2019:
    • To better align with CMS, Cigna is implementing MUE for CPT codes 88300-88309, 90791-90792 and 90832-90839.
    • The MUE rules apply frequency limitations as defined by CMS based on anatomic considerations, HCPCS or CPT code descriptors, CPT instructions, CMS policies, the nature of service or procedure, and clinical judgment or clinical feasibility.

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.