Policy Updates May 2020

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 Update to Coverage
Policies With a Reduction in Coverage
Genetic Testing Panels Reimbursement Policy - (R28)
  • We will rebundle CPT codes used to bill for individual tests that comprise a nucleic acid sexually transmitted diseases (STD) laboratory panel into a single panel code.
  • Submitted claims will be processed and reimbursed using the appropriate CPT panel code.
  • This update is effective for claims processed on or after May 18, 2020.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective May 15, 2020:
Ambulance Services – (0555) New
  • Provides information regarding emergent and nonemergent ambulance services.
Bathroom and Toilet Equipment and Supplies - (0072) Modified
  • Minor change in coverage criteria/policy:
    • Added new whirlpool HCPCS code to existing not covered policy statement.
Liver Transplantation - (0355) Modified
  • Advance notification of important changes in coverage criteria, effective August 15, 2020:
    • Added criterion for hepatocellular carcinoma requiring alpha-fetoprotein (AFP) level less than or equal to 1000 nanograms per milliliter (ng/mL).
    • Clarified language about unresectable cholangiocarcinoma and hepatoblastoma.
Omnibus Codes - (0504) Modified
  • Important changes in coverage criteria:
    • Removed section on cryoablation of lung tumors (CPT code 32994) from pulmonary section:
      • Code removed from precertification.
    • Reviewed gastroenterology section and oncology section:
      • No changes.
Plasma Brain Natriuretic Peptide in the Outpatient Setting - (0028) Modified
  • Important changes in coverage criteria:
    • Updated existing policy statement coverage language to distinguish between heart failure and primary lung disease in dyspneic individuals.
Seat Lift Mechanism, Patient Lifts and Standing Devices - (0343) Modified
  • Minor changes in coverage criteria/policy:
    • Added Rifton E-pacer to policy statement for a combination transfer and mobility device.
      • Similar to the Rifton TRAM device added last year.
    • Corrected HCPCS codes in standing frame policy statement section.
Stuttering Devices - (0366) Retired
  • No longer has business value; therefore, will no longer be maintained.
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • Two Cigna-ASH CPGs were updated with no changes in coverage.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Cigna-eviCore cobranded High-Tech Radiology (HTR or Imaging) Guidelines Modified
  • Advance notification of updates, posted May 1, 2020, and effective July 31, 2020, to:
    • Abdomen Adult
    • Breast Adult
    • Cardiac Adult
    • Chest Adult
    • Head Adult
    • Head Pediatric
    • Musculoskeletal Adult
    • Neck Adult
    • Pelvis Adult
    • Peripheral Vascular Disorders Adult
    • Spine Adult
Radiation Therapy Guidelines Modified
  • Updates effective May 8, 2020:
    • Include unchanged guidelines and guidelines with positive coverage changes.
  • Updates effective August 1, 2020:
    • Include new vulvar cancer guideline and guidelines with adverse changes in coverage, which include IGRT, pancreatic, small cell, and Xofigo guideline updates.
Policies Status Details
Administrative Policies
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective May 1, 2020:
Alemtuzumab - (2001) New
  • Separates medical infused products from Multiple Sclerosis Therapy – Oral and Subcutaneous - (1402)
    • Effective May 8, 2020.
    • Added age restriction for use in individuals less than 17 years of age.
    • Expanded coverage to include treatment of active secondary progressive multiple sclerosis:
      • Responsive to FDA label update.
    • Expanded coverage by exempting individuals with documented highly active or aggressive multiple sclerosis from having to fail two disease modifying therapies:
      • Responsive to updated American Academy of Neurology guidelines.
    • Updated to exclude use in clinically isolated syndrome (CIS) and nonrelapsing forms of multiple sclerosis.
    • Added reauthorization criteria.
Natalizumab for Multiple Sclerosis - (2002) New
  • Separates medical infused products from Multiple Sclerosis Therapy – Oral and Subcutaneous - (1402)
    • Effective May 8, 2020.
    • Added age restriction for use in individuals less than 18 years of age.
    • Updated criteria to better convey intent to exempt individuals with documented highly active or aggressive multiple sclerosis from having to fail one disease modifying therapy.
    • Updated to exclude use in nonrelapsing forms of multiple sclerosis.
    • Added reauthorization criteria, requiring initial criteria be met.
Ocrelizumab – (2003) New
  • Separates medical infused products from Multiple Sclerosis Therapy – Oral and Subcutaneous - (1402)
    • Effective May 8, 2020.
    • Added age restriction for use in individuals less than 18 years of age.
    • Expanded coverage to include progressive-relapsing multiple sclerosis.
    • Added reauthorization criteria, requiring initial criteria be met.
Golodirsen – (2005) New
  • Supports medical precertification requirements of Vyondys 53, effective May 15, 2020.
Luspatercept – (2006) New
  • Supports medical precertification requirements of Reblozyl, effective May 15, 2020.
Alpha1-Proteinase Inhibitors – (4037) Modified
  • Important changes in coverage criteria:
    • Added “prior to initiation of therapy” statement to criteria for FEV1 of 30-65% of predicted value.
    • Added “COPD without Alpha1-PI deficiency” and “Bronchiectasis without Alpha1-PI deficiency” as additional experimental, investigational, or unproven (EIU) uses.
Avatrombopag – (P0079) Modified
  • Important changes in coverage criteria:
    • Added coverage criteria based on new FDA-approved indication (June 2019) for use in adults with chronic immune thrombocytopenia (ITP) who have had insufficient response to previous treatment.
Butalbital Combination Products - (P0066) Modified
  • Minor changes in coverage criteria/policy:
    • Clarified criteria intent for liquid formulations, Vanatol LQ and Vanatol S:
      • Added example for inability to use, addressing ability to swallow.
Cholic Acid – (P0009) Modified
  • Important changes in coverage criteria:
    • Added specifics regarding testing required for bile acid synthesis disorders due to single enzyme defects (SEDs) and peroxisomal disorders (PDs), including Zellweger spectrum disorders:
      • Responsive to guideline support from the North American and European societies for pediatric gastroenterology, hepatology, and nutrition.
    • Added specialist requirement.
    • Revised continuation criteria to state (in addition to initial response to treatment) that individual does not have complete biliary obstruction and added specialist requirement.
Eltrombopag – (9003) Modified
  • Important changes in coverage criteria:
    • Added coverage criteria for thrombocytopenia treatment in individuals with myelodysplastic syndrome (MDS):
      • Responsive to NCCN clinical practice guideline recommendations
    • Added immune thrombocytopenia (ITP) criterion screening for bleeding risk/platelet count:
    • Revised initial treatment option criterion:
      • Responsive to Cigna-ASH clinical practice guideline (CPG) updates for immune thrombocytopenia.
      • Follows formatting of same criterion in avatrombopag, fostamatinib and romiplostim policies.
    • Revised initial authorization interval consistent with other thrombocytopenia medication policies; from six months to three months.
Erythropoiesis Stimulating Agents (ESA) – (5016) Modified
  • Important changes in coverage criteria:
    • Added individual and family plan (IFP) specific coverage criteria for Epogen to require preferred product, Procrit, effective January 1, 2020.
    • Defined criterion for presence of adequate iron stores in line with NCCN and KDIGO recommendations for thresholds when iron deficiency requires management/repletion.
    • Removed criterion screening for an Hgb increase by 1 g/dL for continuation of treatment in individuals receiving chemotherapy.
    • Enhanced chronic kidney disease anemia criteria to allow approval for individuals on dialysis without any additional requirements.
    • Defined chronic kidney disease anemia criteria for individuals not on dialysis detailing requirements for use in adults and in pediatrics.
    • Defined hepatitis C treatment anemia criteria to include a criterion screening to verify individual is currently receiving ribavirin in combination with interferon treatment.
    • Added criterion for preoperative anemia to screen an individual is not able to donate autologous blood before surgery.
    • Revised pretreatment Hgb from < 11 g/dL to < 10 g/dL for zidovudine-related anemia.
    • Added criterion screening an individual currently receiving zidovudine for zidovudine-related anemia.
Flibanserin - (P0002) Modified
  • Important changes in coverage criteria:
    • Added statement requiring individual to have been female at birth:
      • FDA label limitation of use.
    • Updated indication statement responsive to evolution of the diagnosis nomenclature.
    • Excluded use in individuals currently being treated for depression as hypoactive sexual desire disorder (HSDD)/female sexual interest/arousal disorder (FSIAD).
    • Added requirement for patient to be counseled regarding the interaction of alcohol and Addyi:
      • FDA warning/precaution.
    • Added requirement for individual to have had normal sexual desire before diagnosis of HSDD/FSIAD:
      • Inclusion criteria from clinical trials in the label.
    • Added requirement for symptom history of at least six months:
      • Inclusion criteria from clinical trials in the label.
    • Decreased initial authorization time limit to eight weeks:
      • FDA dosing recommendation.
    • Decreased reauthorization time limit to six months.
    • Updated exclusion statement for use in postmenopausal women:
      • FDA label limitation of use.
Fostamatinib – (P0081) Modified
  • Important changes in coverage criteria:
    • Added minimum age criterion of 18 years of age and older:
      • Tavalisse is not recommended for individuals less than age 18 years due to adverse events on actively growing bones (as observed in studies).
    • Revised initial treatment option criterion:
      • Responsive to Cigna-ASH CPG updates for immune thrombocytopenia; CPGs no longer address a place in treatment for immunoglobulins.
      • Updated CPG supports rituximab as a primary treatment option that can be considered with/without corticosteroids.
Histrelin Acetate Subcutaneous Implant – (8008) and Triptorelin pamoate – (M0009) Modified
  • Important changes in coverage criteria:
    • Added statement for use in treatment of gender dysphoria and link to Treatment of Gender Dysphoria – (0266) medical coverage policy above criteria stem.
    • Added additional example of “confirmation of diagnosis” beyond just the GnRH stimulation test:
      • Expanded criteria bullet to include one the following:
        • Pubertal basal level of luteinizing hormone (LH) greater than or equal to 0.3 mIU/ml.
        • Pubertal luteinizing hormone (LH) response to GnRH stimulation testing.
HIV Products – (P0050) Modified
  • Minor changes in coverage criteria/policy:
    • Added Symtuza to preferred brand HIV products list for employer group benefit plans:
      • Responsive to business decision to remove prior authorization requirement and to add to preferred brand tier on all prescription drug list plans.
Human Chorionic Gonadotropin (hCG) for Non-fertility – (1815) Modified
  • Important changes in coverage criteria:
    • Added statement above criteria stem to refer to Infertility Injectables – (1012), which addresses hCG uses related to fertility.
    • Added initial and reauthorization criteria language of six months.
    • Updated to current template format and language.
    • Reformatted EIU statement for treatment of low testosterone for added clarity:
      • Added “Note” to redirect to Infertility Injectables – (1012) if hCG is being used to stimulate spermatogenesis in hypogonadotropic hypogonadism.
      • hCG is considered EIU to treat low testosterone for any other purpose.
Interferon Gamma-1b – (P0001) Modified
  • Important changes in coverage criteria:
    • Added specific requirements for confirmation of disease for both chronic granulomatous disease and severe malignant osteopetrosis:
      • Responsive to guideline support including the American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy and Asthma & Immunology (ACAAI).
Medication Administration Site of Care - (1605) Modified
  • Minor changes in coverage criteria/policy:
    • Added to the “Enhanced Specialty Care Options” program list in policy background, supporting redirection of site of care for:
      • Givlaari (givosiran)
      • Tepezza (teprotumumab)
      • Vyepti (eptinezumab)
Multiple Sclerosis Therapy – Oral and Subcutaneous - (1402) Modified
  • Important changes in coverage criteria, effective May 8, 2020:
    • Reorganized and retitled policy to consist only of oral and subcutaneous multiple sclerosis therapies.
      • Moved intravenous products to separate policies.
    • Updated employer group Aubagio criteria:
      • Decreased number of required prerequisites from five to four.
    • Incorporated Vumerity as preferred brand for employer groups.
      • Remains nonpreferred brand for IFPs.
    • Added EIU use of nonrelapsing forms of multiple sclerosis:
      • Use has not been established for any of the products.
Nonsteroidal Anti-inflammatory Drugs - (P0057) Modified
  • Minor changes in coverage criteria/policy:
    • Updated Indocin oral suspension criteria to an “ease of swallowing” approach.
    • Clarified Sprix criteria intent:
      • Added example for inability to use.
    • Removed quantity limitation information from Sprix criteria box.
Omalizumab – (4026) Modified
  • Important changes in coverage criteria:
    • For allergen-related asthma stem:
      • Added specialist requirement:
        • Allergist, immunologist, pulmonologist.
      • Added inhaled long-acting muscarinic antagonist (LAMA) and theophylline to inadequately controlled with inhaled corticosteroids (ICS) and long-acting beta agonist (LABA) or leukotriene receptor antagonist:
        • Responsive to specialist support.
    • For chronic idiopathic urticarial (CIU) stem:
      • Removed requirement of an H2 antagonist for chronic idiopathic urticarial.
      • Revised requirement of using second generation antihistamine to four times the recommended dose to align to clinical practice guidelines.
      • Added specialist requirement:
        • Allergist, immunologist, dermatologist.
Rilonacept – (P0007) Modified
  • Important changes in coverage criteria:
    • Added diagnosis of neonatal onset multisystem inflammatory disease (NOMID) and chronic infantile neurological cutaneous and articular (CINCA) syndrome:
      • Responsive to clinical literature support that these conditions are along a spectrum of disease severity for cryopyrin-associated periodic syndrome (CAPS).
    • Added specialist requirement.
    • Added no concurrent biologic therapy use with Arcalyst, with a reference list added to the background:
      • Arcalyst should not be administered in combination with another biologic agent for an inflammatory condition.
Rituximab for Non-Oncology Indications – (5108) Modified
  • Minor changes in coverage criteria/policy:
    • Revised language regarding individuals previously started on or currently receiving Rituxan therapy.
Romiplostim – (9002) Modified
  • Important changes in coverage criteria:
    • Added coverage criteria for thrombocytopenia treatment in individuals with MDS:
      • Responsive to NCCN clinical practice guideline recommendations.
    • Revised initial treatment option criterion:
      • Responsive to Cigna-ASH CPG updates for immune thrombocytopenia; however, as FDA approved use still states that romiplostim is used after a trial of immune globulin, this initial therapy option remains.
    • Revised initial authorization interval consistent with other thrombocytopenia medication policies; from six months to three months.
Skeletal Muscle Relaxants - (P0071) Modified
  • Minor changes in coverage criteria/policy:
    • Added chlorzoxazone 375 mg and 750 mg (recently launched to the market) to existing chlorzoxazone 250mg criteria.
Sublingual Allergen Immunotherapy – (1902) Modified
  • Important changes in coverage criteria:
    • Removed upper age limit of 65 years old.
    • Reworded testing language to add additional detail and clarity.
      • Not a content change.
    • Added no concurrent use of sublingual allergen immunotherapy agents to EIU section.
    • Removed leukotriene receptor antagonists as required alt for Grastek, Odactra, Oralair, Ragwitek, noting a black box update for possible serious mental health side effects with montelukast and FDA advising restricting use for allergic rhinitis.
Tetracycline Antibiotics – (P0100) Modified
  • Minor changes in coverage criteria/policy:
    • Updated to note that all Ximino ER formulations are not covered and subject to prior authorization medical necessity review:
      • Responsive to business decision.
Zolpidem - (P0069) Modified
  • Minor changes in coverage criteria/policy:
    • Added example for inability to use, addressing ability to swallow, to better define criteria intent for the Edluar, Intermezzo and Zolpimist criteria statements.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for May 2020
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
COVID-19 Interim Billing Guidelines – (R33) New
  • Effective March 2, 2020:
    • Outlines billing guidelines for services rendered during the COVID-19 pandemic.
Care Integration Services – (R32) Modified
  • Important changes, effective May 16, 2020:
    • Removed CPT codes 99492, 99493, 99494, and 99484 from the not separately reimbursed code list.
National Correct Coding Initiatives (NCCI) editing for Facilities – (R09) Modified
  • Advance notification of important changes, effective August 16, 2020:
    • Added additional code pairs to the current NCCI code edit list to more closely align with industry standard.
Omnibus Reimbursement Policy – (R24) Modified
  • Advance notification of important changes, effective August 18, 2020:
    • Updated to note that Cigna is aligned with CMS in requiring the use of HCPCS code G0416 for billing prostate needle biopsy surgical pathology exam.
    • Cigna will not reimburse CPT code 88305 for this service
Policies Status Details
ClaimsXten*
Code Edit and Policy Guidelines and Code Edit Bulletin
  • Added the following statement:
    • Cigna is in alignment with the edits outlined by CMS with the exception of the removals CMS instituted during the COVID-19 crisis. Cigna will continue to apply the edits initially instituted by CMS.

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] July differ significantly from the standard benefit plans upon which these policies are based. For example, a customer's benefit plan document July 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 July be used to support medical necessity and other coverage determinations.