Policy Updates November 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.

Infusion and injection administration services with emergency department as place of service,

*Facility Routine Services, Supplies and Equipment (R12)

*Pharmacy and Infusion Services (R14)

  • We will deny claims from emergency departments for infusion and injection administration services because infusion and injection administration services are considered incidental to the primary service – and are therefore not separately reimbursable.
  • This update applies to claims that are billed with revenue codes 450-459 when the emergency department is the place of service, and with Current Procedural Terminology (CPT®) codes 96360-96379 and 96521-96523.
  • Please note that our current Facility Routine Services, Supplies, and Equipment (R12) and Pharmacy and Infusion Services (R14) reimbursement policies indicate that we deny these services when billed by an outpatient facility. Expanding the policies to include emergency departments will help ensure claims are processed consistently regardless of place of service.
  • This update is effective for claims processed on or after November 11, 2018.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective November 15, 2018:
Diagnostic Microbe Testing for Sexually Transmitted Diseases (STD) – (0530) New
  • Advance notification of policy posting November 15, 2018; effective February 15, 2019:
    • New policy identifies medically necessary ICD10 codes/CPT code pairs for diagnostic microbe testing for:
      • Chlamydia
      • Gardnerella
      • Genital Herpes (Herpes Simplex Virus Types 1 and 2)
      • Gonorrhea (Neisseria gonorrhea)
      • Human Papillomavirus (HPV)
      • High-risk types (e.g., types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)
      • Invasive Candidiasis
      • Candidemia
      • Trichomonas
      • Syphilis
    • Reflects that molecular testing is not medically necessary for:
      • Noninvasive or mucosal candidiasis (e.g., vaginal candidiasis)
      • HPV
      • Low-risk types (e.g., types 6, 11, 42, 43, 44)
      • Syphilis
    • Includes reimbursement note that use of “not otherwise specified” codes is not reimbursable when a more specific code is available.
Stem Cell Transplantation: Blood Cancers – (0533) New
  • Consolidates eight existing coverage policies into one.
  • Retiring existing policies; no changes to actual coverage criteria:
    • Stem-Cell Transplantation for Acute Lymphocytic /Lymphoblastic Leukemia – (0163)
    • Stem-Cell Transplantation for Acute Myelogenous Leukemia – (0164)
    • Stem-Cell Transplantation for Chronic Myelogenous Leukemia and Chronic Lymphocytic Leukemia – (0242)
    • Stem-Cell Transplantation for Chronic Myelomonocytic Leukemia (CMML) and Juvenile Myelomonocytic Leukemia (JMML) – (0243)
    • Stem-Cell Transplantation for Hodgkin Disease – (0188)
    • Stem-Cell Transplantation for Multiple Myeloma, POEMS Syndrome and Amyloidosis – (0294)
    • Stem-Cell Transplantation for Myelodysplastic Syndrome – (0187)
    • Stem-Cell Transplantation for Non-Hodgkin Lymphoma – (0263)
Bone Mineral Density Measurement - (0300) Modified
  • Originally provided advance notification of important changes in coverage criteria on August 15, 2018; effective November 15, 2018:
    • Added new experimental, investigational or unproven (EIU) policy statement for CPT code 0508T (Pulse-echo ultrasound bone density measurement, tibia).

Intraoperative Monitoring - (0509)

Modified
  • Important changes in coverage criteria:
    • Added to existing not medically necessary policy statement:
      • Monitoring of epidural injections.
      • Monitoring during radiofrequency ablation/denervation procedures.
      • Monitoring during placement of spinal cord stimulator or an intrathecal pain pump.
Myoelectric Devices: Upper Limb – (0233) Modified
  • Important changes in coverage criteria:
    • Changed title from Prosthetic Devices: Upper Limb Myoelectric to Myoelectric Devices: Upper Limb.
    • Added EIU policy statement for myoelectric upper extremity orthotic device.
Omnibus Codes - (0504) Modified
  • Important changes in coverage criteria:
    • Added Intracardiac Ischemia Monitoring System
      • AngelMed Guardian® system received FDA approval April 2018.
      • Remains EIU.
    • Removed codes that are not managed or implemented:
      • Intravascular Optical Coherence Tomography (OCT) (Coronary Native Vessel or Graft):
        • CPT codes 92978 and 92979.
      • Intravascular Catheter-Based Coronary Vessel or Graft Spectroscopy:
        • CPT code 0205T.
      • Intermittent and Continuous Measurement of Wheeze Rate for Bronchodilator or Bronchial Challenge:
        • CPT code 94799.
    • Moved from policy statement section to EIU table:
      • MarginProbe®:
        • CPT code 19499.
      • Conjunctival Incision with Posterior Extrascleral Placement of a Pharmacological Agent:
        • CPT code 68399.
      • Multivariate Analysis of Patient Specific Findings with Quantifiable Computer Probability Assessment:
        • CPT code 99199.
      • Suprachoroidal Delivery of Pharmacological Agent:
        • CPT code 67299.
Transcatheter Heart Valve Procedures - (0501) Modified
  • Important changes in coverage criteria:
    • Added coverage policy statement on transcatheter aortic valve implantation for intermediate surgical risk patients.
    • Added EIU policy statement on transcatheter mitral valve repair and replacement.
Nerve Conduction Velocity Studies – (0117) Retired
Somatosensory Evoked Potentials – (0122) Retired
Spinal Ultrasound – (0246) Retired
Stem-Cell Transplantation for Acute Lymphocytic /Lymphoblastic Leukemia – (0163) Retired
Stem-Cell Transplantation for Acute Myelogenous Leukemia – (0164) Retired
Stem-Cell Transplantation for Chronic Myelogenous Leukemia and Chronic Lymphocytic Leukemia – (0242) Retired
Stem-Cell Transplantation for Chronic Myelomonocytic Leukemia (CMML) and Juvenile Myelomonocytic Leukemia (JMML) – (0243) Retired
Stem-Cell Transplantation for Hodgkin Disease – (0188) Retired
Stem-Cell Transplantation for Multiple Myeloma, POEMS Syndrome and Amyloidosis – (0294) Retired
Stem-Cell Transplantation for Myelodysplastic Syndrome – (0187) Retired
Stem-Cell Transplantation for Non-Hodgkin Lymphoma – (0263) Retired
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)

Electrodiagnostic Testing (EMG/NCV) – (CPG 129),

Physical Performance Test or Measurement – (CPG 295),

Spinal Ultrasound – (CPG 038)

New New policies November 2018.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Modified
  • Originally provided advance notification August 15, 2018 for changes effective November 15, 2018 of the following Cigna-eviCore Cobranded Imaging Guidelines:
    • Abdomen (Adult and Pediatric
    • Breast (Adult only)
    • Chest (Adult and Pediatric)
    • Head (Adult and Pediatric)
    • Musculoskeletal (Adult and Pediatric)
    • Neck (Adult and Pediatric)
    • Pelvis (Adult and Pediatric)
    • Peripheral Vascular Disease (PVD) (Adult and Pediatric)
    • Peripheral Nerve Disease (PND) (Adult and Pediatric)
    • Spine (Adult and Pediatric)
Policies Status Details
Administrative Policies
  • No updates for November 2018.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective November 15, 2018:
Calcitonin Gene-Related Peptide (CGRP) Inhibitors – (1813) New
  • Supports pharmacy prior authorization of Aimovig (erenumab-aooe).
Cannabidiol - (1814) New
  • Supports pharmacy prior authorization.
Etelcalcetide - (1812) New
  • Supports medical precertification.
Nitrofurantoin Suspension – (P0059) New
  • Supports medical necessity review for employer group benefit plans.
Antiemetic Therapy - (1705) Modified
  • Important change in coverage criteria:
    • Added new generic palonosetron hydrochloride to support medical precertification.

Belimumab - (1114)

Modified
  • Important changes in coverage criteria:
    • Added criteria not allowing for concurrent use of biological therapies for systemic lupus erythematosus (SLE).
Clotting Factors and Antithrombin - (8007) Modified
  • Important change in coverage criteria:
    • Added criteria for expanded FDA-approved indication for hemophilia A (congenital factor VIII deficiency) without inhibitors.
Dose Optimization - (1804) Modified
  • Important change in coverage criteria:
    • Added statement to gastrointestinal section:
      • “Effective December 31, 2018, the Proton Pump Inhibitors listed below will be removed from the dose optimization program.”
Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List - (1601) Modified
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:
      • Butalbital 50 mg-acetaminophen 300 mg capsules
      • Minolira ER
      • TaperDex (1.5 mg tablets) 12 Day and 6 Day.
Dupilumab - (1810) Modified
  • Important change in coverage criteria:
    • Added criteria for FDA-approved indication for add-on maintenance treatment for moderate to severe asthma.
Filgrastim – (1611) Modified
  • Important change in coverage criteria:
    • Added Nivestym (filgrastim-aafi) to support coverage as non-preferred brand (NPB) with a Specialty prior authorization.
    • Removed “or not a candidate (for example: pediatric individual) for” language because FDA approved expanded use of Granix to pediatric patients one month and older.
Hereditary Angioedema (HAE) Therapy - (1019) Modified
  • Important changes in coverage criteria:
    • Added Takhzyro interim criteria.
    • Added interim criteria updates made to Cinryze and Haegarda.
    • Added reauthorization criteria for HAE agents when the following criteria are met:
      • Evidence of beneficial clinical response.
      • Pretreatment clinical condition met the initial criteria for the specific drug.
Immune Globulin – (5026) Modified
  • Important change in coverage criteria:
    • Added new immune globulin, Panzyga, to support medical precertification.
Oncology Medications – (1403) Modified
  • Important changes in coverage criteria:
    • Added Copiktra and Vizimpro to pharmacy benefit table.
    • Added arsenic trioxide and Libtayo® to medical benefit table.
Pegfilgrastim - (1320) Modified
  • Important change in coverage criteria:
    • Added Fulphila to support prior authorization.
Pharmacy Prior Authorization - (1407) Modified
  • Important changes in coverage criteria:
    • Added interim criteria for Auvi-Q 0.1 mg/0.1 mL.
    • Updated background to include new Auvi-Q strength.
Pulmonary Hypertension - (6121) Modified
  • Important change in coverage criteria:
    • Added generic Adcirca (tadalafil) to stem:
      • Same criteria as Adcirca.
Sacubitril-Valsartan (P0016) Modified
  • Important change in coverage criteria:
    • Removed utilization management criteria for employer group plans.
Teduglutide - (1318) Modified
  • Important changes in coverage criteria:
    • Updated formatting of criteria stem, which included definition of “adult”.
    • Removed criteria element of at least 12 month dependence on parenteral support:
      • No specific timeframe now.
Topical Doxepin - (P0054) Modified
  • Important changes in coverage criteria:
    • Added indication and age criteria.
    • Added use for neuropathic pain is considered EIU.
Unassigned Drug or Biologic Code Medical Precertification – (1701) Modified
  • Important change in coverage criteria:
    • Added Trogarzo (Ibalizumab-uiyk) to support medical precertification:
      • No specific code has been assigned.
      • Until a code is assigned, the unclassified biologic code J3590 will be used.
Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use - (1206) Modified
  • Important change in coverage criteria:
    • Updated EIU statement to current standard.
    • Moved EIU indications from background to criteria stem statement.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • One policy updated for November 2018.
Policies Status Details
Precertification Policies*
The Master Precertification List was updated.
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
No updates for November 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.