Policy Updates November 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective November 15, 2017:
Peripheral Nerve Ablation for Pain Conditions – (0525) New
  • Advance posting (November 15, 2017) of policy effective February 15, 2018:
    • Will be implemented with a procedure-to-diagnosis (PXDX) edit on CPT codes 64640 and 64632 when billed with certain pain conditions.
    • Includes coverage policy statement for peripheral nerve destruction for treatment of trigeminal neuralgia refractory to other alternative treatments.
    • No change in coverage (not part of new edit).
Deep Brain, Motor Cortex and Responsive Cortical Stimulation – (0184) Modified
  • Important change in coverage criteria:
    • Added new experimental, investigational or unproven (EIU) policy statement for directional deep brain stimulations (e.g., Infinity DBS system).
Hospice Care – (0462) Modified
  • Important change in coverage criteria:
    • Clarified coverage criteria for respite and hospice care.
      • No change in coverage.
Miscellaneous Musculoskeletal Procedures – (0515) Modified
  • Important changes in coverage criteria:
    • Added new EIU policy statement for pre-operative advanced imaging studies associated with customized knee replacement.
      • Previously considered not medically necessary (NMN).
    • Added Carticel® and MACI® products to existing EIU policy statement for autologous chondrocyte implantation for treatment of articular cartilage defects in locations other than the distal femur of the knee.
      • No change in coverage.
Pneumatic Compression Devices and Compression Garments - (0354) Modified
  • Important changes in coverage criteria:
    • Advance posting (November 15, 2017) of updates effective February 15, 2018:
    • Changed pneumatic pumps for edema from covered to not covered.
    • Removed “refractory edema” from existing covered policy statement.
    • Removed ICD10 code R60.0 (localized edema) from covered diagnosis codes.
    • Changed pneumatic pumps in the home setting for arterial insufficiency from covered to not covered.
    • Added “a pump for arterial insufficiency (HCPCS code E0675)” to the existing not covered policy statement.
    • HCPCS code E0675 will have an “Always EIU” edit.
Transcatheter Closure of Cardiovascular Defects – (0011) Modified
  • Important change:
    • Updated title from Transcatheter Closure of Septal Defects to Transcatheter Closure of Cardiovascular Defects.
Tumor Profiling, Gene Expression Assays and Molecular Diagnostic Testing for Hematology/Oncology Indications – (0520) Modified
  • Important change in coverage criteria:
    • Added coverage for MammaPrint® 70-Gene Breast Cancer Recurrence Assay.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective November 15, 2017:
Belimumab - (1114) Modified
  • Important changes in coverage criteria:
    • Updated coverage criteria to reflect availability of subcutaneous formulation.
    • Removed SELENA-SLEDAI score requirement and specified that treatment is for active systemic lupus erythematosus (SLE).
    • Modified receipt of standard therapy for SLE to failure or inadequate response
      • Removed nonsteroidal anti-inflammatory drugs.
    • Removed trade name from title.
Hereditary Angioedema Therapy - (1019) Modified
  • Important changes in coverage criteria:
    • Added coverage criteria for Haegarda.
    • Modified criteria for history of attacks to characterize as either moderate or severe.
    • Added criteria to not allow for concomitant use of Haegarda and Cinryze.
Lysosomal Storage Disorders Therapy - (1319) Modified
  • Important changes in coverage criteria:
    • Removed age specification for Strensiq.
    • Removed Myozyme (discontinued).
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Added abemaciclib (Verzenio), copanlisib (Aliqopa®) and gemtuzumab ozogamicin (Mylotarg).
Topical Alpha Adrenergic Agonists - (1401) Modified
  • Important changes in coverage criteria:
    • Added oxymetazoline topical cream (Rhofade) as not covered:
      • FDA approved indication is cosmetic.
    • Updated title from “Brimonidine Topical Gel” to the class of products.
Ferric Carboxymaltose (Injectafer) - (1607) Retired
  • Medical precertification no longer required, effective November 10, 2017.
Policies Status Details
Administrative Policies
Unless otherwise noted, the following medical coverage policies were modified effective November 15, 2017:
Preventive Care – (A004) Modified
  • Important changes:
    • Updated guidelines for:
      • Cholesterol screening for adults.
      • HIV infection screening for women.
    • Added routine immunization codes:
      • CPT codes 90750 and 90756.
    • Added ICD-10 codes Z13.88, Z71.83 in Code Group 1.
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*
Master Outpatient Precertification List Modified
Policies Status Details
Reimbursement Policies*
R14 Pharmacy and Infusion Services Modified
R24 Omnibus Reimbursement Policy (R24) Modified
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
No updates for November 2017
Policies Status Details
Policies with a Reduction in Coverage
We are changing how we reimburse for the following policy for claims processed on or after November 12, 2017.
Uniform Billing Editor We will deny claims processed on or after November 12, 2017, that do not include both the required Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes in the Field Locator 44 (FL44) field on the outpatient (UB) claim.

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.