Policy Updates October 2016

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective October 15, 2016:
Benign Prostatic Hyperplasia (BPH) Treatments – (0159) Modified
  • Important changes in coverage criteria:
    • Added two treatments to the existing not covered policy statement:
      • Waterjet tissue ablation (e.g., AquaBeam System)
      • Water vapor thermal therapy (e.g., Rezūm System)
Colorectal Cancer Screening and Surveillance – (0148) Modified
  • Important changes in coverage criteria:
    • Changed stool-based deoxyribonucleic acid (DNA) testing (i.e., Cologuard) for colorectal cancer screening from not covered to covered.
Dermabrasion and Chemical Peels – (0505) Modified
  • Important changes in coverage criteria:
    • Changed rationale of existing not covered policy statement for dermal chemical peels from experimental, investigational, or unproven (EIU) to cosmetic and not medically necessary (NMN).
Omnibus Codes – (0504) Modified
  • Important changes in coverage criteria:
    • Added coverage for Tumor Treatment Fields (TTF) Therapy in newly diagnosed glioblastoma.
    • Added not covered policy statement for treatment-planning software (i.e., NovoTAL).
    • Removed section on noninvasive calculation and analysis of central arterial pressure waveforms.
Orthognathic Surgery – (0209) Modified
  • Important changes in coverage criteria:
    • Added disclaimer that computer technologies, including 3D imaging, as part of orthognathic surgery are considered integral to the base procedure.
Stem-Cell Transplantation for Acute Lymphocytic/Lymphoblastic Leukemia - (0163) Modified
  • Important changes in coverage criteria:
    • Added coverage for nonmyeloablative allogeneic hematopoietic stem-cell transplantation (HSCT) for adults.
    • Added coverage of autologous HSCT for adults.
Transcatheter Heart Valve Procedures – (0501) Modified
  • Important changes in coverage criteria:
    • Added Edwards SAPIEN device to existing policy statement for transcatheter pulmonary valve implantation.
    • Added not covered policy statement for percutaneous tricuspid valve repair.
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Unless otherwise noted, the following coverage policies were modified effective October 15, 2016:
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 medical necessity criteria to support noncoverage of Zembrace SymTouch on the Standard and Performance drug lists.
Hepatitis C Therapy - (1316) Modified
  • Important changes in coverage criteria:
    • Added Epclusa, Viekira XR, and Zepatier coverage criteria.
    • Added preference for Epclusa in genotype 2 and 3.
      • Harvoni remains the preferred agent for genotypes 1, 4, 5, and 6.
    • Added off-label coverage of Technivie for genotype 4 and cirrhosis.
    • Expanded coverage of Daklinza in combination with Sovaldi and Epclusa for genotypes 2 and 3 for sofosbuvir-experienced individuals.
    • Removed coverage of Sovaldi in combination with pegylated interferon and ribavirin:
      • Considered NMN as it is not a recommended treatment regimen by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidance for hepatitis C therapy.
    • Limited coverage of Sovaldi in combination with ribavirin to genotype 2 and post-liver transplant (only circumstance where AASLD/IDSA guidance recommends this regimen) and genotypes 1, 2, 3, or 4 and hepatocellular carcinoma awaiting liver transplant.
Immune Globulin Intravenous (Human) (IVIG) - (5026) Modified
  • Important changes in coverage criteria:
    • Increased initial authorization from three to six months.
    • Increased reauthorization period for primary immunodeficiency to 12 months.
      • Reauthorization period remains six months for all other indications.
    • Added impaired antibody response to hyperimmunoglobulin E syndrome criteria.
    • Reformatted dermatomyositis/polymyositis criteria.
    • Updated and aligned infection criteria for acquired immunosuppression, B-cell chronic lymphocytic leukemia, and multiple myeloma.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Reformatted specific additional criteria for enzalutamide (Xtandi).
Medication-Assisted Treatment for Opioid Dependence - (1413) Retired
  • Business decision to remove products from pharmacy prior authorization.
Policies Status Details
Administrative Policies
No updates for October 2016
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Seventeen policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
*Please log in to view these policies.
Policies Status Details
Precertification Policies*
Unless otherwise noted, the following policies were modified effective October 15, 2016:
Master Precertification List Modified
  • Important update to the communication for the July precertification changes:
    • Balloon sinuplasty codes added to precert were inadvertently listed as 32195, 32196 and 32197.
    • Codes actually added were 31295, 31296 and 31297.
  • Important changes – effective on October 1, 2016:
    • Added codes 89337, 93228, 93229, C9139, C9481 and C9483.
    • Removed codes E0652, 74712, 74713, 33254, 33255, 33257, 33258, 33265 and 33266.
Policies Status Details
Reimbursement Policies*
Unless otherwise noted, the following policies were modified effective October 15, 2016:
R13 Implant Billing Requirements Modified
  • Important changes:
    • Updated template.
    • Clarified several reimbursement statements.
    • Retired the list of coverage policies with implants.
R14 Pharmacy and Infusion Services Modified
  • Important changes:
    • Added requirement for the use of Modifier JW
      • Change began on October 3, 2016.
HCPCS - Healthcare Common Procedure Coding System (HCPCS) National Level ll Modifiers Modified
  • Important changes:
    • Added requirement for the use of Modifier JW
      • Change began on October 3, 2016.
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
Code Editing Policy and Guidelines Modified
  • On November 12, 2016, ClaimsXten will be updated to Fourth Quarter Knowledge Base content and NCCI Version 22.3 for all medical and behavioral claims we process.
Policies Status Details
Policies with a Reduction in Coverage
Policy updates for October 2016 that resulted in a reduction of coverage.
R12 Facility Routine Services, Supplies and Equipment Reimbursement Policy
  • Consistent with our reimbursement policy, we will deny all cardiac and vascular catheters and guide wires billed separately regardless of the amount billed.
  • Affected HCPCS codes include: C1769, C1725, C1887, C1751, C1730, C1733, C1732, C1753, C1759, C1731, C1893, C1766, C2628, C1757, C1892, and C1885
  • Administrative appeal rights will be provided.
  • For claims processed on or after October 3, 2016.
R14 Pharmacy and Infusion Services
  • We will update our reimbursement policy to allow a JW modifier for waste when a single dose vial (SDV) is billed for infusion services and drugs.
  • For claims processed on or after October 16, 2016.
R24 Omnibus Reimbursement Policy
  • We will update our reimbursement policy to align with the AANS definition of cervical vertebral corpectomy.
  • Claims submitted with the affected Current Procedural Terminology (CPT®) codes 63081 and 63082 that do not meet the AANS criteria will be denied.
  • Administrative appeal rights will be provided.
  • For claims processed on or after October 16, 2016.
Routine Immunizations – (9001)
  • On June 22, 2016, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) voted that FluMist should not be used during the 2016-2017 flu season because the effectiveness of the vaccine is lower than expected.
  • Therefore, we will deny CPT codes 90660 and 90672, which are used to bill claims for FluMist.
  • We will cover routine immunizations based on a vaccine being licensed by the U.S. Food and Drug Administration (FDA) and recommended by ACIP.
  • For dates of service on or after September 15, 2016.

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.