Policy Updates October 2017

Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective October 15, 2017:
Benign Prostatic Hyperplasia Treatments - (0159) Modified
  • Important changes in coverage criteria:
    • Clarified prostate volume requirement.
    • Changed requirement for conventional medical therapy from six to three months.
Colorectal Cancer Screening and Surveillance - (0148) Modified
  • Important change in coverage criteria:
    • Added new test to existing experimental, investigational, or unproven (EIU) policy statement:
      • Urine-based test for detection of adenomatous polyps (e.g., PolypDX).
Kidney Transplantation, Pancreas-Kidney Transplantation, and Pancreas Transplantation Alone - (0146) Modified
  • Important changes in coverage criteria:
    • Added coverage for pancreas transplant for type 2 diabetes mellitus:
      • Previously covered for type 1 diabetes mellitus only.
    • Added requirement to simultaneous pancreas-kidney (SPK) transplantation:
      • Medical necessity for kidney transplantation must be met.
      • Not a change in coverage.
    • Added requirement to pancreas-after-kidney (PAK) transplantation:
      • Medical necessity for pancreas transplantation alone must be met.
      • Not a change in coverage.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective October 1, 2017:
Abatacept - (6112) Modified
  • Important changes in coverage criteria:
    • Added Actemra and Stelara as preferred brands for Employer Group Benefit Plans.
    • Modified criteria to require two preferred biologic products where FDA indicated.
    • Added coverage criteria for psoriatic arthritis.
Anakinra - (4063) Modified
  • Important changes in coverage criteria:
    • Added Actemra and Stelara as preferred brands for Employer Group Benefit Plans.
    • Modified criteria to require two preferred biologic products where FDA indicated.
Anti-Tumor Necrosis Factor Therapy - (9014) Modified
  • Important changes in coverage criteria:
    • Added Actemra and Stelara as preferred brands for Employer Group Benefit Plans.
    • Modified criteria to require two preferred biologic products where FDA indicated.
Interleukin-12/23 and 17 Antagonists - (1017) Modified
  • Important changes in coverage criteria:
    • Added Actemra and Stelara as preferred brands for Employer Group Benefit Plans.
    • Modified criteria to require two preferred biologic products where FDA indicated.
    • Added coverage criteria for plaque psoriasis for brodalumab (Siliq).
Tocilizumab - (1024) Modified
  • Important changes in coverage criteria:
    • Added Actemra and Stelara as preferred brands for Employer Group Benefit Plans.
    • Modified criteria to require two preferred biologic products where FDA indicated.
    • Added coverage criteria for giant cell arteritis and cytokine release syndrome.
Tofacitinib - (1410) Modified
  • Important changes in coverage criteria:
    • Added Actemra and Stelara as preferred brands for Employer Group Benefit Plans.
    • Modified criteria to require two preferred biologic products where FDA indicated.
Vedolizumab - (1502) Modified
  • Important changes in coverage criteria:
    • Added Actemra and Stelara as preferred brands for Employer Group Benefit Plans.
    • Modified criteria to require two preferred biologic products where FDA indicated.
Apremilast - (1414) Modified
  • Important change in coverage criteria:
    • Added coverage criteria for psoriatic arthritis.
Hepatitis C Therapy - (1316) Modified
  • Important changes in coverage criteria:
    • Added Mavyret (glecaprevir/pibrentasvir) coverage criteria supporting pharmacy prior authorization.
      • Mavyret is a preferred product for Employer Group Benefit Plans.
    • Updated coverage criteria for all products included in the policy:
      • Based on updated guidance from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on treatment of hepatitis C infection.
The following drugs & biologics coverage policies were modified effective October 15, 2017:
Deflazacort - (1708) New
  • Supports pharmacy prior authorization of deflazacort (Emflaza).
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 Tresiba and Levemir as preferred brand.
Immune Globulin - (5026) Modified
  • Important changes in coverage criteria:
    • Updated criteria for multiple myeloma to align with National Comprehensive Cancer Network (NCCN) guidelines.
    • Removed coverage of maternal-fetal transmission of HIV in women in their third trimester of pregnancy.
    • Added the following as EIU uses:
      • Hashimoto's encephalitis
      • Maintenance therapy for myasthenia gravis
      • Neonatal sepsis
      • Primary progressive multiple sclerosis (MS)
      • Secondary progressive MS
      • Acute MS exacerbations
      • Clinically isolated syndrome
Interleukin (IL)-5 Antagonists: Mepolizumab and Reslizumab - (1608) Modified
  • Important change in coverage criteria:
    • Added eosinophilic granulomatosis with polyangitis as an example of "other esinophilic conditions" under EIU uses.
Nusinersen - (1707) Modified
  • Important change in coverage criteria:
    • Expanded coverage to include spinal muscular atrophy (SMA) types 2 and 3.
Oncology Medications - (1403) Modified
  • Important change in coverage criteria:
    • Added:
      • Vyxeos (daunorubicin and cytarabine)
      • Besponsa (inotuzumab ozogamicin)
      • Kymriah (tisagenlecleucel)
Step Therapy - (1109) Modified
  • Important changes in coverage criteria:
    • Moved esomeprazole strontium from step 3 to step 1.
    • Removed Vascepa as a target drug from emerging step therapy.
    • Added Flolipid on step 3.
Policies Status Details
Administrative Policies
Unless otherwise noted, the following medical coverage policies were modified effective October 15, 2017:
Emergency Room Services - (A005) New
  • Advance notification of new policy posted October 1, 2017, with changes effective January 1, 2018:
    • Documents coverage of emergency room (ER) services for the Individual Family Plan (IFP) product.
    • Uses prudent layperson language to determine what qualifies as an emergency and warrants coverage for ER visits in nonparticipating facilities.
    • Visits to a nonparticipating ER for a non-emergent condition will no longer be paid.
Policies Status Details
CareAllies Medical Necessity Guidelines
Various Modified Twenty policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
*Please log in to view these policies.
Policies Status Details
Precertification Policies*
Master Outpatient Precertification List Modified
Policies Status Details
Reimbursement Policies*
R19 Hospital Acquired Conditions Modified
Policies Status Details
Claim Editing Policies and Procedures* ClaimsXten
Code Editing Policy and Guidelines Modified
  • Important changes:
    • On November 12, 2017, ClaimsXten will be updated to Fourth Quarter Knowledge Based content and NCCI Version 23.3 for all medical and behavioral claims.
    • Added new rule titled "Global Obstetric Care" listed under "Code Editing (ClaimsXten) and/or Rule."
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.