Policy Updates October 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
We are changing how we reimburse for the following policies:
*Evaluation and Management (R30)
  • We will implement a new reimbursement policy, Evaluation and Management (R30), and deny claims billed with Current Procedural Terminology (CPT®) consultation codes as not valid.
  • The affected CPT codes are 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, and 99255.
  • The policy is effective for claims processed beginning October 19, 2019.
Scrotal Ultrasound – (0548) and Head and Neck Ultrasound – (0549)
  • We will implement two new medical coverage policies, Scrotal Ultrasound (0548) and Head and Neck Ultrasound (0549), and apply medical necessity criteria for scrotal ultrasounds and head and neck ultrasounds.
  • The affected CPT codes are 76536 and 76870.
  • The policies are effective for dates of service beginning October 21, 2019.
Angioplasty (Extracranial, Intracranial) and Endoluminal Flow Diverting Stents - (0545)
  • We will implement a new medical coverage policy, Angioplasty (Extracranial, Intracranial) and Endoluminal Flow Diverting Stents (0545), and require precertification for extracranial and intracranial angioplasty and endoluminal flow diversion procedures. We will review for medical necessity of the procedure and the level of care.
Implantable Electrocardiographic Event Monitors - (0547)
  • We will implement a new medical coverage policy, Implantable Electrocardiographic Event Monitors (0547), to review the use of these devices for medical necessity.
  • This update affects claims billed with CPT code 33285 and Healthcare Common Procedure Coding System (HCPCS) codes C1764 and E0616.
  • The policy is effective for dates of service beginning October 25, 2019.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective October 15, 2019:
Angioplasty (Extracranial, Intracranial) and Endoluminal Flow Diverting Devices – (0545) New
  • Originally provided advance notification on July 15, 2019, effective October 15, 2019:
    • Addresses medical necessity of certain angioplasty procedures.
    • Precertification required.
Head and Neck Ultrasound – (0549) New
  • Originally provided advance notification on July 18, 2019, effective October 21, 2019.
    • Addresses medical necessity of ultrasound of soft tissues of the head and neck.
Implantable Electrocardiographic Event Monitors – (0547) New
  • Originally provided advance notification on July 18, 2019, effective October 25, 2019:
    • Precertification required.
Scrotal Ultrasound – (0548) New
  • Originally provided advance notification on July 18, 2019, effective October 21, 2019:
    • Addresses medical necessity of ultrasound of the scrotum.
Corneal Remodeling for Refractive Errors – (0141) Modified
  • Minor changes in coverage criteria/policy:
    • Updated title from Corneal Remodeling to current title.
    • Removed qualifying verbiage about progressive deterioration in vision from existing policy statement.
Cryounits/Cooling Devices - (0314) Modified
  • Important change in coverage criteria:
    • Added new not medically necessary (NMN) policy statement for scalp cooling.
Genetic Testing for Hereditary and Multifactorial Conditions - (0052) Modified
  • Important change in coverage criteria:
    • Changed policy statement rationale from experimental, investigational or unproven (EIU) to NMN for certain indications.
Intervertebral Disc (IVD) Prosthesis - (0104) Modified
  • Minor change in criteria/policy:
    • Updated existing EIU policy statement with criteria about treatment at adjacent or other level.
Kidney Transplantation, Pancreas-Kidney Transplantation, and Pancreas Transplantation Alone - (0146) Modified
  • Important changes in coverage criteria:
    • Removed some criteria requirements in existing policy statement for simultaneous pancreas-kidney (SPK) transplantation.
    • Revised policy statement criteria for pancreas transplantation alone (PTA) and pancreas-after-kidney transplantation (PAK).
Nonpharmacological Treatments for Atrial Fibrillation – (0469) Modified
  • Important changes in coverage criteria:
    • Updated title from Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins for the Treatment of Atrial Fibrillation to current title.
    • Added policy statement for coverage of transcatheter ablation of the pulmonary veins.
    • Added percutaneous transcatheter closure of the left atrial appendage (LAA) information from Omnibus Codes – (0504), maintaining EIU position.
    • Added surgical occlusion of the LAA to existing EIU policy statement.
    • Added policy statement for coverage of the surgical Maze or modified Maze procedure.
    • Added policy statement that minimally invasive off-pump Maze procedure, including a hybrid or convergent ablation procedure considered EIU.
Nucleic Acid Pathogen Testing – (0530) Modified
  • Originally provided advance notification of important changes in coverage criteria on August 1, 2019, effective November 1, 2019:
    • Removed coverage for several symptom-related diagnosis codes related to Gardnerella.
      • Will continue to cover for high-risk behaviors.
    • Clarified the asymptomatic bullet of first policy statement.
Omnibus Codes - (0504) Modified
Sacral Nerve Stimulation for Urinary Voiding Dysfunction and Fecal Incontinence - (0404) Modified
  • Important changes in coverage criteria:
    • Updated language in existing policy statement about screening trial.
    • Removed some criteria requirements from existing policy statement.
    • Added new policy statement for coverage of maintenance therapy.
Tumor Profiling, Gene Expression Assays, and Molecular Diagnostic Testing for Hematology/Oncology Indications - (0520) Modified
  • Important changes in coverage criteria:
    • Changed “mutation” to “pathogenic” or “likely pathogenic” for clarity.
    • Revised criteria for gene expression classifier testing.
    • Added criteria for medical necessity of the Breast Cancer Index test and EndoPredict test.
    • Added statement to reflect that the Oncotype DX Breast DCIS Score is EIU.
    • Added medical necessity criteria for AR-V7 circulating tumor cell testing.
    • Amended policy statement to reflect somatic testing for selected solid neoplasms remains EIU unless required for management of tumor agnostic pharmacologic therapy.
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • No updates for October 2019.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
High-Tech Radiology (HTR or Imaging) guidelines Modified
  • Updated Adult Oncology, effective November 1, 2019.
Radiation Therapy guidelines Modified
  • Important changes, effective October 15, 2019 include:
    • Anal and rectal cancers divided into two separate guidelines.
    • Coverage added for palliation for anal cancer.
Radiation Therapy guidelines Modified
  • Important changes, effective January 15, 2020:
    • All radiation therapy guidelines posted on October 14, 2019, to allow for 90-day notification; changes include:
      • Multiple Myeloma and Solitary Plasmacytomas (new policies).
      • Thymoma and Thymic Cancer (new policies).
      • Image-guided radiation therapy (IGRT) - change in coverage re: the use of IGRT to the left breast only when a deep inspiration breath hold (DIBH) technique is being used to minimize radiation to the heart.
      • Endometrial - statement on brachytherapy with vaginal cylinder changed from covered to EIU.
      • Cervical - statement on brachytherapy with vaginal cylinder changed from covered to EIU.
      • Skin - statement on brachytherapy with vaginal cylinder changed from covered to EIU.
Policies Status Details
Administrative Policies
Preventive Care Services - (A004)
  • Important updates:
    • Abdominal Aortic Aneurysm (AAA) Screening:
      • Removed codes for AAA screening:
        • CPT codes 76700, 76705, 76770, and 76775
        • HCPCS code G0389.
      • Reworded Preventive Care Services to reflect updated guidance:
        • Updated “Alcohol and substance abuse/misuse” to “Unhealthy Alcohol and substance abuse screening/counseling”.
        • Updated “Domestic and interpersonal violence screening/counseling” to “Intimate partner/interpersonal violence screening/referral to support services”.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective October 1, 2019:
Brexanolone – (1905) New
  • Supports medical precertification for the treatment of postpartum depression.
Onasemnogene Abeparvovec-axgt (Zolgensma®) – (1904 New
  • Supports medical precertification for the treatment of Spinal Muscular Atrophy (SMA).
Antitussives - (P0083) Modified
  • Important changes in coverage criteria responsive to business decisions:
    • Added prior authorization to all opioid-containing cough suppressants for non-acute (less than 21 days) on standard, performance, value, advantage, and legacy formularies.
    • Added prior authorization/NMN to individuals under the age of 18.
Chimeric Antigen Receptor T-Cell (CAR-T) and Advanced Cellular/Immune Effector Cell Therapy – (1808) Modified
  • Important changes in coverage criteria:
    • Added AIDS-related B-cell lymphoma, human herpes virus 8-positive diffuse large B-cell lymphoma, and post-transplant lymphoproliferative disorders [B-cell type] to large B-cell lymphoma diagnosis types’ criterion for both Yescarta and Kymriah.
    • Added axicabtagene ciloleucel (Yescarta) to the no prior use of Yescarta criterion because there is no data to support CAR-T therapy retreatment is efficacious.
    • Added tisagenlecleucel (Kymriah) to the no prior use of Kymriah criterion because there is no data to support CAR-T therapy retreatment is efficacious.
Drugs/Biologics 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 responsive to business decisions:
    • Removed Trulance (plecanatide) criteria.
    • Removed criteria for mesalamine 800 mg DR (delayed release).
    • Revised criteria for Colazal (balsalazide), Delzicol (mesalamine), Dipentum (olsalazine), Giazo (balsalazide) to include generic mesalamine as an added alternative.
    • Revised criteria for Asacol HD (mesalamine) to require intolerance or inability to use generic mesalamine as a required alternative.
    • Removed Dulera (mometasone/salmeterol) criteria and moved to preferred agent.
  • Additional important changes in coverage criteria:
    • Modified brand Advair Diskus (fluticasone/salmeterol) and AirDuo Respiclick (fluticasone/salmeterol) criteria with addition of Dulera as a covered alternative.
    • Removed Anti-Parkinson Agents: Gocovri, Lodosyn, Requip XL, Zelapar as they are now in a stand-alone coverage policy.
  • Important changes in coverage criteria responsive to business decisions, effective January 1, 2020:
    • Removed Spiriva as therapeutic alternative for Seebri Neohaler and Tudorza Pressair.
    • Added Spiriva Handihaler and Spiriva Respimat medical necessity criteria.
    • Added Striverdi Respimat medical necessity criteria.
    • Removed Stiolto as therapeutic alternative for Bevespi Aerosphere and Utibron Neohaler.
    • Added Stiolto Respimat medical necessity criteria
      • The above drugs will no longer be covered products.
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 responsive to business decisions:
    • Removed Trulance (plecanatide) criteria.
    • Removed criteria for mesalamine 800 mg DR (delayed release).
    • Revised criteria for Colazal (balsalazide), Delzicol (mesalamine), Dipentum (olsalazine), Giazo (balsalazide) to include generic mesalamine as an added alternative.
    • Revised criteria for Asacol HD (mesalamine) to require intolerance or inability to use generic mesalamine as a required alternative.
    • Removed Dulera (mometasone/salmeterol) criteria and moved to preferred agent.
  • Additional important changes in coverage criteria:
    • Modified brand Advair Diskus (fluticasone/salmeterol) and AirDuo Respiclick (fluticasone/salmeterol) criteria with addition of Dulera as a covered alternative.
    • Removed Anti-Parkinson Agents: Gocovri, Lodosyn, Requip XL, Zelapar as they are now in a stand-alone coverage policy.
  • Important changes in coverage criteria responsive to business decisions, effective January 1, 2020:
    • Added Striverdi Respimat medical necessity criteria.
    • Modified Arcapta Neohaler criteria to remove Striverdi Respimat as a therapeutic alternative and added Serevent Diskus as therapeutic alternative.
      • The above drugs will no longer be covered products.
    • Modified Spiriva Respimat 1.25 mcg criteria to include other formulary alternatives (Pulmicort Flexhaler, Qvar/Qvar Redihaler) and allow fulfillment of criteria if history of combination therapy of an ICS plus another controller therapy.
    • Removed Serevent Diskus criteria:
      • Will be a preferred product.
Hepatitis C Therapy – (1316) Modified
  • Important changes in coverage criteria responsive to business decisions:
    • Updated preferred products for Individual and Family Plan.
      • Products added include the authorized generics for Epclusa, sofosbuvir/velpatasvir and Harvoni, ledipasvir/sofosbuvir.
Infertility Injectables - (1012) Modified
  • Important changes in coverage criteria responsive to business decisions:
    • Modified follitropin (Bravelle, Follistim AQ, Gonal-F) criteria to require step-through preferred product, Gonal-F, as Follistim AQ is no longer preferred product.
Ivabradine – (P0010) Modified
  • Important changes in coverage criteria responsive to business decisions:
    • Added new expanded pediatric heart failure secondary to dilated cardiomyopathy indication criteria, which included:
      • Individual less than 18 years of age secondary to clinical trial design.
      • Left ventricular ejection fraction less than or equal to 45 percent secondary to clinical trial design.
      • Normal sinus rhythm or sinus tachycardia secondary to prescribing information and clinical trial design.
    • Updated adult heart failure criteria:
      • Added age requirement of 18 years and older secondary to prescribing information and clinical trial design.
      • Updated “normal sinus rhythm” criterion to reflect population with elevated heart rate or tachycardia secondary to prescribing information, clinical trial design, and potential for inappropriate denials.
Multiple Sclerosis Therapy - (1402) Modified
  • Important changes in coverage criteria:
    • Added Mayznet as a preferred product
    • Added Mavenclad as a non-preferred product.
    • Moved Aubagio from a preferred product to a non-preferred product for employer group benefit plans, responsive to business decision, effective January 1, 2020.
      • Criteria to support the business decision will require documented failure, contraindication per FDA label, intolerance, or not a candidate (for example, stabilized condition where therapeutic interchange is inappropriate) for five preferred products.
Oncology Medications - (1403) Modified
  • Important changes in coverage criteria:
    • Added Rozlytrek (entrectnib) and Inrebic (fedratinib dihydrochloride) to pharmacy benefit table.
    • Updated specific additional criteria requiring use of generic abiraterone before brand, effective January 1, 2020 for all lines of business.
Penicillamine and trientine hydrochloride – (1703) Modified
  • Important changes in coverage criteria, effective Janaury 1, 2020:
    • Added criteria for brand Syprine responsive to business decision.
Step Therapy - (1109) Modified
  • Important changes in coverage criteria responsive to business decisions:
    • Removed Trulance (plecanatide) step therapy.
    • Removed step therapy for mesalamine 800 mg DR (delayed release).
    • Added diclofenac epolamine 1.3% topical patch as a step 3 medication to the Non-Steroidal Anti-Inflammatory Drugs table.
    • Added ramelteon (generic Rozerem) as a Step 1 agent to the Hypnotics table.
    • Added halobetasol propionate 0.05% foam (generic Lexette) as a Step 1 agent to the Very High Potency Topical Anti-inflammatory table.
  • Additional important changes in coverage criteria:
    • Modified Dulera (mometasone/salmeterol) to a Step 2 agent.
    • Removed Trelegy step-edit.
Step Therapy - Standard/Performance Prescription Drug Lists (Employer Group Plans) - (1801) Modified
  • Important changes in coverage criteria responsive to business decisions::
    • Added diclofenac epolamine 1.3% topical patch as a step 3 medication to the Non-Steroidal Anti-Inflammatory Drugs table.
    • Added ramelteon (generic Rozerem) as a Step 1 agent to the Hypnotics table.
    • Added halobetasol propionate 0.05% foam (generic Lexette) as a Step 1 agent to the Very High Potency Topical Anti-inflammatory table.
  • Additional important changes in coverage criteria:
    • Removed Trelegy step-edit.
    • Added hydrocortisone butyrate 1% lotion formulation as a Step 1 agent to the Topical Inflammatory, Medium Potency table as product should have be included.
    • Clarified desvenlafaxine ER Step 1 agent under Antidepressants as this is the generic for Pristiq.
    • Clarified desvenlafaxine ER Step 3 agent under Antidepressants as this is Khedezla.
Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803) Modified
  • Important changes in coverage criteria responsive to business decisions::
    • Removed Trulance (plecanatide) step therapy.
    • Removed step therapy for mesalamine:
      • Removed as a step 3 medication and added as a step 1 medication.
    • Added diclofenac epolamine 1.3% topical patch as a step 3 medication to the Non-Steroidal Anti-Inflammatory Drugs table.
    • Added ramelteon (generic Rozerem) as a Step 1 agent to the Hypnotics table.
    • Added halobetasol propionate 0.05% foam (generic Lexette) as a Step 1 agent to the Very High Potency Topical Anti-inflammatory table.
  • Additional important changes in coverage criteria:
    • Modified Dulera (mometasone/salmeterol) to a Step 2 agent.
    • Removed Trelegy step-edit.
    • Added hydrocortisone butyrate 1% lotion formulation as a Step 1 agent to the Topical Inflammatory, Medium Potency table as product should have be included.
    • Clarified desvenlafaxine ER Step 1 agent under Antidepressants as this is the generic for Pristiq.
    • Clarified desvenlafaxine ER Step 3 agent under Antidepressants as this is Khedezla.
Lesinurad – (P0014) Retired
  • Retired due to manufacturer removal of products from market for non-safety reasons.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for October 2019
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
  • No updates for October 2019.

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.