Policy Updates October 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.
Cardiac Resynchronization Therapy

  • As a result of a recent review of our Cardiac Resynchronization Therapy (CRT) coverage policy, we will require precertification for services billed with Current Procedural Terminology (CPT®) codes 33224 and 33225.
  • We currently require precertification for the insertion or replacement of a single or dual chamber defibrillator (CPT 33249), but not for the resynchronization process.
  • Please note that precertification requests for all services billed with CPT codes 33224, 33225, and 33249 will be reviewed by a cardiologist for medical necessity.
  • These changes are effective for dates of service on or after October 1, 2018.
Genetic testing update

  • We currently require precertification for many genetic testing CPT® codes. Some of these codes, however, are not considered medically necessary for any condition, or are considered experimental, investigational, or unproven (EIU). Currently because we do not cover services that are not medically necessary or are EIU, providers routinely request precertification for many of these services that are denied.
  • To remove the administrative burden of having to request precertification for services that will always be denied, we will no longer require you to obtain precertification for these codes. Please note, however, that because these services are not considered medically necessary for any condition or are EIU, we will still deny these services when submitted on a claim.
  • Additionally, to ensure consistency in how we reimburse these services, we will deny these codes when submitted on either a CMS-1500 or UB-04 claim form.
  • This change is effective for dates of service on October 22, 2018.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective October 15, 2018:
Cardiac Electrophysiological (EP) Studies – (0532) New
  • Advance notification of new policy effective January 1, 2019
Benign Prostatic Hyperplasia (BPH) Treatments - (0159) Modified
  • Important changes in coverage criteria:
    • Added “temporary implantable nitinol device (TIND)” to existing not covered policy statement.
Electrical Stimulation Therapy and Home Devices - (0160) Modified

Miscellaneous Musculoskeletal Procedures – (0515)

Modified
Sacral Nerve and Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation – (0404) Modified
  • Important changes in coverage criteria:
    • Added percutaneous tibial nerve stimulation (PTNS) for urinary incontinence, fecal incontinence and constipation using content from Invasive Treatments for Urinary Incontinence – (0365) and Electrical Stimulation Therapy and Home Devices - (0160).
      • No change in coverage.
      • Retiring Invasive Treatments for Urinary Incontinence – (0365).
    • Added policy statement that PTNS for fecal incontinence is experimental, investigational and unproven (EIU).
    • Clarified policy statement on non-coverage for Sacral Nerve Stimulation (SNS):
      • Added “including constipation”.
Invasive Treatments for Urinary Incontinence – (0365) Retired
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
No new policies or updates made for October 2018.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
Cigna-eviCore cobranded Radiation Therapy Guidelines Modified
  • Advance notification of annual updates (effective January 1, 2019) to all Radiation Therapy Guidelines
Cigna-eviCore cobranded High-tech Radiology (HTR or Imaging) Guidelines Modified
  • Updated the Adult Oncology Imaging guideline (effective October 3, 2018) for prostate cancer and paraneoplastic syndromes.
Cigna-eviCore cobranded Comprehensive Musculoskeletal Management (CMM) Guidelines Modified
Policies Status Details
Administrative Policies
Preventive Care Services - (A004) Modified
  • Important changes in coverage criteria effective October 1, 2018:
    • Updated screening services and coding table for Colorectal Cancer Screening.
    • Updated coding table for Wellness Diagnosis ICD-10 Code Group 1.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective October 15, 2018:
Indomethacin Suppository – (P0057) New
  • Supports medical necessity criteria; effective January 1, 2019.
Pegvaliase-pqpz - (P0055) and Topical Doxepin – (P0056) New
  • Supports medical necessity criteria; effective October 15, 2018
Benralizumab, Mepolizumab, Reslizumab - (1608) Modified
  • Important changes in coverage criteria:
    • Removed eosinophilic granulomatosis with polyangiitis (EGPA) from EIU section.
Deflazacort - (1708) Modified
  • Important change in coverage criteria:
    • Added reauthorization criteria.
Enzyme Related Therapies - (1319) Modified
  • Important changes in coverage criteria:
    • Added Mepsevii, Galafold, and Sucraid®.
    • Modified genetic testing criteria to include more specific information.

Immune Globulin - (5026)

Modified
  • Important changes in coverage criteria:
    • Aligned initial authorization criteria with reauthorization criteria:
      • Documentation of objective measurement of general findings on initial examination for the neurological neuromuscular disorder, Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) required.
Nusinersen - (1707) Modified
  • Important changes in coverage criteria:
    • Updated genetic testing requirements to remove spinal muscular atrophy (SMA) mutation.
    • Added statement excluding use in individuals requiring permanent ventilation.
    • Added requirement for documentation of:
      • Baseline motor function for initial criteria.
      • A positive clinical response for reauthorization criteria.
Oncology Medications – (1403) Modified
  • Important changes in coverage criteria:
    • Added Poteligeo® (mogamulizumab-kpkc) to medical benefit table.
    • Added Yonsa (abiraterone) specific criteria:
      • Documented intolerance to preferred formulation of abiraterone (Zytiga) required.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • One policy updated for October 2018.
Policies Status Details
Precertification Policies*
Master Precertification List
  • Updates made to:
    • Added Proprietary Laboratory Analyses (PLA) codes.
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
Code Edit and Policy Guidelines
  • Important changes effective November 11, 2018:
    • ClaimsXten will be updated to Fourth Quarter Knowledge Base content and NCCI Version 24.3 for all medical and behavioral claims.
    • The Anesthesia Crosswalk, Anesthesia Crosswalk 2, and Anesthesia Not Eligible rules will reflect updated editing applied as part of rule maintenance by Change Healthcare.

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.