Policy Updates November 2016

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective November 15, 2016:
Comparative Genomic Hybridization Testing (Chromosomal Microarray Analysis) for Autism Spectrum Disorders, Developmental Delay, Intellectual Disability and Multiple Congenital Anomalies - (0493) Modified
  • Important changes in coverage criteria:
    • Expanded coverage to all ages by removing age limit of 13 years.
Obstructive Sleep Apnea Diagnosis and Treatment Services - (0158) Modified
  • Important changes in coverage criteria:
    • Added language addressing coverage of follow-up sleep testing.
Oxygen for Home Use – (0207) Modified
  • Important changes in coverage criteria:
    • Added coverage for portable and stationary oxygen systems.
    • Clarified examples of duplicate oxygen equipment.
Tissue-Engineered Skin Substitutes - (0068) Modified
  • Important changes in coverage criteria:
    • Added coverage for Grafix® and Integra® (Omnigraft) Dermal Regeneration Template for the treatment of partial- and full-thickness diabetic foot ulcers.
    • Added 25 new products to existing not covered policy statement/table.
Varicose Vein Treatments - (0234) Modified
  • Important changes in coverage criteria:
    • Added coil embolization to existing not covered policy statement.
    • Clarified acronyms to endomechanical ablative approaches.
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Unless otherwise noted, the following coverage policies were modified effective November 15, 2016:
Ferric Carboxymaltose (Injectafer®) - (1607) New
  • Supports medical precertification of the intravenous iron product, Injectafer.
    • Other available intravenous iron products do not require precertification.
Obeticholic Acid (Ocaliva®) - (1610) New
  • Supports pharmacy prior authorization.
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 criteria:
    • Added criteria for Treximet to support medical necessity review.
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 criteria:
    • Added criteria to support medical necessity review for:
      • Treximet
      • Byvalson
Immune Globulin Intravenous (Human) (IVIG) - (5026) Modified
  • Important changes in coverage criteria:
    • Restructured criteria for dermatomyositis or polymyositis to clarify intent.
Lysosomal Storage Disorders Therapy - (1319) Modified
  • Important changes in coverage criteria:
    • Updated criteria for all products to include documented diagnosis:
      • Requires submission of laboratory and other clinical findings to support diagnosis.
    • Expanded coverage of Cerezyme, Elelyso®, and VPRIV® for Gaucher disease type 3.
    • Added Kanuma® for lysosomal acid lipase deficiency.
    • Added criteria for Strensiq:
      • Individual must have onset of hypophosphatasia (HPP) at 12 years of age or younger based on the inclusion criteria from the pivotal trial in juvenile HPP.
    • Separated criteria for Lumizyme® and Myozyme®.
      • Added criteria that Myozyme is for infantile-onset Pompe disease.
Quantity Limitations – (1201) Modified
  • Important changes in coverage criteria:
    • Added lidocaine 5% ointment.
    • Added new strength of Treximet.
Policies Status Details
Administrative Policies
No updates for November 2016
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Sixteen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
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Policies Status Details
Precertification Policies*
No updates for November 2016
Policies Status Details
Reimbursement Policies*
Unless otherwise noted, the following policies were modified effective November 15, 2016:
Updated Policy Templates Modified
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
No updates for November 2016
Policies Status Details
Policies with a Reduction in Coverage
The following policy updates, effective November 14, 2016, will result in a reduction of coverage.
Minimally Invasive Intradiscal/Annular Procedures and Trigger Piint injections - (0139)
  • Consistent with our coverage policy, we will deny claims for ultrasound guidance (CPT code 76942) when billed with trigger point injections (CPT codes 20552 and 20553) as experimental, investigational, or unproven (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.