Policy Updates November 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 Update to Coverage
Policies With a Reduction in Coverage
There were no additional changes made in November 2019 that resulted in a reduction in coverage.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective November 15, 2019:
Allergy Testing and Non-Pharmacologic Treatment - (0070) Modified
  • Advance notification of important changes in coverage criteria, effective February 15, 2020:
    • Adding focused review of frequency for in vivo and in vitro allergy testing:
      • CPT code 86003: limit to 80 units.
      • CPT code 95004: limit to 80 units.
      • CPT code 95024: limit to 40 units.
Corneal Remodeling for Refractive Errors – (0141) Modified
  • Important changes in coverage criteria:
    • Updated title.
    • Updated criteria and coding.
Gastric Pacing/Gastric Electrical Stimulation (GES) - (0103) Modified
  • Important change in coverage criteria:
    • Added policy statement for temporary gastric electrical stimulation (GES).
  • Genetic Testing for Hereditary and Multifactorial Conditions - (0052) Modified
    • Minor changes in coverage criteria/policy:
      • Updated single gene testing, multigene testing for multifactorial conditions, and newborn screening.
    Omnibus Codes - (0504) Modified
    • Important changes in coverage criteria:
      • Removed transluminal peripheral atherectomy in arteries above the inguinal ligaments:
        • Renal, visceral, abdominal aorta, brachiocephalic trunk and branches and iliac artery.
        • CPT codes 0234T, 0235T, 0236T, 0237T and 0238T.
      • Added new FDA indication for chronic baroreceptor stimulation of the carotid sinus:
        • Premarket approval (PMA) granted for Barostim Neo system for improvement of symptoms of heart failure.
        • Use of device remains experimental, investigational and unproven (EIU).
        • CPT codes 0266T, 0267T, 0268T, 0269T, 0270T, 0271T, 0272T and 0273T.
      • Added permanent cardiac contractility modulation system:
        • Previously in the not FDA approved section.
        • The OPTIMIZER® Smart System received FDA PMA in March 2019 and has been moved to the cardiovascular section.
        • Device considered EIU.
        • CPT codes 0408T, 0409T, 0410T, 0411T, 0412T, 0413T, 0414T, 0415T, 0416T, 0417T and 0418T.
    Pharmacogenetic Testing - (0500) Modified
    • Important change in coverage criteria, effective November 18, 2019:
      • Added CPT code 81227 as medically necessary when billed with ICD10 diagnosis code G35 - multiple sclerosis.
        • All other ICD10 codes remain not medically necessary (NMN).
    Serological Testing for Inflammatory Bowel Disease - (0121) Modified
    • Important changes in coverage criteria:
      • Added serum drug level testing for the management of inflammatory bowel disease to existing EIU policy statement.
      • Updated policy statement to address the class of drugs used to treat inflammatory bowel disease rather than listing specific drugs.
      • Updated examples of test panels to read the test name and removed the drug name being tested.
    Staff-Assisted Home Hemodialysis - (0229) Modified
    • Minor change in criteria/policy:
      • Added disclaimer re: home health care benefits to clarify the service for staff-assisted home dialysis is subject to the home health care benefit.
    Tumor Profiling, Gene Expression Assays, and Molecular Diagnostic Testing for Hematology/Oncology Indications - (0520) Modified
    • Important change in coverage criteria:
      • Changed CPT code 81500 (representing the Risk of Ovarian Malignancy Algorithm [ROMA®]) test from EIU to medically necessary.
        • No policy statement change.
    Pulmonary Rehabilitation – (0212) Retired
    • Retired on August, 17, 2019.
    • No longer has business value; therefore, will no longer be maintained.
    Policies Status Details
    American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
    Biofeedback – (CPG 294) Modified
    • Minor changes in coverage criteria/policy.
    Policies Status Details
    Cigna-eviCore Cobranded Guidelines
    High-Tech Radiology (HTR or Imaging) guidelines Modified
    • Advance notification of updates to all 24 cobranded High-tech Radiology (HTR) (Imaging) policies, including the Preface document, effective February 14, 2020..
    Adult and Pediatric Oncology Imaging guidelines Modified
    • Posting a “positive changes only” version of the Adult and Pediatric Oncology Imaging guidelines, effective December 2, 2019.
    Policies Status Details
    Administrative Policies
    • No updates for November 2019
    Policies Status Details
    Pharmacy (Drugs & Biologics) Policies
    Unless otherwise noted, the following pharmacy coverage policies were modified effective November 1, 2019:
    Deflazacort - (1708) Modified
    • Important changes in coverage criteria:
      • Expanded coverage by lowering minimum age from five to two years of age, aligning to the updated FDA label.
      • Updated prednisone prerequisite statement to require six months of prednisone therapy.
    Enzyme Related Therapies – (1319) Modified
    • Important changes in coverage criteria:
      • Removed Adagen as product is being discontinued.
      • Revised criteria to match genetic testing standards.
      • Revised criteria for Lumizyme for Pompe Disease to match genetic testing standards.
      • Added no concomitant use allowed with Gaucher disease therapies.
      • For Fabrazyme, mirrored language for Galafold that concomitant use is not allowed with these two therapies.
      • For Cerdelga, added intermediate metabolizer to an acceptable metabolizer type and added indeterminate metabolizer for EIU use.
    Migraine Treatment – (P0058) Modified
    • Important changes in coverage criteria responsive to business decisions:
      • Updated the following criteria statements to require up to five covered like-formulation products:
        • Ergomar
        • Imitrex injection
        • Imitrex nasal spray
        • Imitrex tablet
        • Migranal
        • Onzetra
        • Zembrace
        • Zomig nasal spray
        • Zomig tablet
        • Zomig ZMT
      • Separated Imitrex injection criteria into migraine and cluster headache statements:
        • Clinically appropriate alternatives differ by headache type.
      • Added the covered oral naratriptan and/or oral zolmitriptan to the list of alternative options, where applicable.
      • Added initial reauthorization time limits of 12 months.
    Oncology Medications - (1403) Modified
    • Minor changes in coverage criteria/policy:
      • Added Asparlas (calaspargase pegol-mknl) to medical precertification table.
      • No content changes to coverage criteria.
    Nusinersen - (1707) Modified
    • Important changes in coverage criteria:
      • Updated documentation of beneficial clinical response example.
      • Added use in an individual previously treated with Zolgensma to EIU statement.
    Pegvaliase-pqpz – (P0055) Modified
    • Important changes in coverage criteria:
      • Added criteria defining documentation of diagnosis of phenylketonuria (PKU) consistent with guidelines and literature.
      • Reworded reauthorization criteria that blood phenylalanine levels are maintained within an acceptable range or that the individual has achieved a greater than or equal to 20 percent reduction in blood phenylalanine levels.
      • Added phrase “once stabilized on Palynziq” to the no concomitant use with Kuvan bullet to allow for titration.
      • Added link to related resources for Sapropterin – (P0022)
    Sapropterin – (P0022) Modified
    • Important changes in coverage criteria:
      • Added criteria defining documentation of diagnosis of PKU consistent with guidelines and literature.
      • Added statement that Kuvan cannot be used concomitantly with Palynziq for consistency with Pegvaliase-pqpz – (P0055).
      • Added reauthorization criteria that blood phenylalanine levels are maintained within an acceptable range or that the individual has achieved a greater than or equal to 20 percent reduction in blood phenylalanine levels.
      • Added bullet that no concomitant use will be allowed with Palynziq to align with Pegvaliase criteria.
      • Added link to related resources for Pegvaliase-pqpz – (P0055).
    Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ocular Use - (1206) Modified
    • Important changes in coverage criteria:
      • Updated Eylea diabetic retinopathy criteria, responsive to a FDA label update.
      • Updated Lucentis criteria statement by expanding coverage, off-label, to include choroidal neovascularization secondary to angioid streaks or pseudoxanthoma elasticum.
      • Added initial and reauthorization time limits of 12 months and reauthorization criteria.
    Policies Status Details
    CareAllies Medical Necessity Guidelines
    • No updates for November 2019
    Policies Status Details
    Precertification Policies*
    Policies Status Details
    Reimbursement Policies*
    Care Integration Services - (R32) New
    • Advance notification of new policy, effective February 15, 2020:
      • We will deny all care integration services as included in the overall care of the customer.
      • Services include:
        • care plan oversight
        • care management
        • transition of care coordination
        • medication therapy management
        • team conferences
        • other associated services involving management of the care of a customer.
    Evaluation and Management Services – (R30) Modified
    • Policy was updated.
    Policies Status Details
    ClaimsXten*
    Code Edit and Policy Guidelines Modified
    • Important changes, effective November 17, 2019:
      • ClaimsXten was updated to Fourth Quarter Knowledge Base content and NCCI Version 25.3 for all medical and behavioral claims.

    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.