Policy Updates Sepetmber 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 policy for claims processed on and after September 16, 2018

Lumbar Laminectomy with Posterior Lumbar Interbody Fusion *Omnibus Reimbursement Policy (R24)

  • We will update our Omnibus Reimbursement Policy (R24) to no longer reimburse claims (with or without a modifier) for a lumbar laminectomy when billed with a posterior lumbar interbody fusion (PLIF). A lumbar laminectomy is considered incidental to the PLIF and should therefore not be separately reimbursable. This update is effective for claims processed on and after September 16, 2018.
Policies Status Details
Medical Coverage Policy
Unless otherwise noted, the following medical coverage policies were modified effective September 15, 2018:
Airway Clearance Devices in the Ambulatory Setting - (0069) Modified
  • Important change in coverage criteria:
    • Added coverage for high-frequency chest wall compression device for the treatment of neuromuscular diseases.
Biventricular Pacing/Cardiac Resynchronization Therapy (CRT) - (0174) Modified
  • Important change in coverage criteria:
    • Added experimental, investigational or unproven (EIU) policy statement for the wireless cardiac resynchronization therapy (CRT) system.
Electrical Stimulation Therapy and Home Devices – (0160) Modified

Fecal Bacteriotherapy (Fecal Microbiota Transplantation) - (0516)

Modified
  • Important change in coverage criteria:
    • Updated treatment regimen criteria to align with 2018 Infectious Diseases Society of America guidelines for C. Difficile.
      • No change in coverage.
Heart, Lung, and Heart-Lung Transplantation - (0129) Modified
  • Important change in coverage criteria:
    • Added EIU policy statement from ex vivo lung perfusion (ELVP).
Nutritional Support - (0136) Modified
  • Important change in coverage criteria:
    • Added EIU policy statement for digestive enzyme cartridge used with enteral feedings.
Omnibus Codes - (0504) Modified
  • Important changes in coverage criteria:
    • Added urology section, addressing two procedures that are currently addressed in Invasive Treatments for Urinary Incontinence – (0365).
      • No change in coverage.
      • Retiring Invasive Treatments for Urinary Incontinence – (0365) effective October 15, 2018.
    • Removed whole body and selective head hypothermia information.
      • No change in coverage.
Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty - (0040) Modified
  • Originally provided advance notification of important changes in coverage criteria on June 15, 2018, with effective date of September 15, 2018:
    • Added imaging requirement.
Prosthetic Devices: Lower Limb (Including Vacuum-Assisted Socket System and Microprocessor/Computer-Controlled Lower Limb Prostheses) - (0194) Modified
  • Important change in coverage criteria:
    • Added duplication or upgrade of a functioning prosthetic device is not medically necessary (NMN).
      • No change in coverage.
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
No new policies or updates made for September 2018.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
  • Originally provided advance notification on June 15, 2018 of updated Cigna-eviCore Cobranded Comprehensive Musculoskeletal Management (CMM 312) Knee Surgery Arthroscopic and Open Guidelines effective September 15, 2018:
    • Reformatted policy statements:
      • Updated language re: function limiting pain.
      • Clarified criteria for osteoarthritis changes.
      • Added NMN statement for each procedure.
    • Added policy statements and criteria for synovectomy and lysis of adhesions.
    • Added NMN statement for autologous chondrocyte transplantation.
    • Added knee subchondroplasty, focal resurfacing and in-office diagnostic arthroscopy to EIU statement.
    • Added statement in general guideline section for case-by-case review and clarified manipulation under anesthesia (MUA) is incidental to an arthroscopic procedure.
      • No change in coverage.
  • Advance notification originally provided on June 15, 2018 of updates to the Cigna-eviCore Cobranded High-Tech Radiology Guidelines for Oncology Imaging (Adult and Pediatric) (effective date of September 15, 2018) noting numerous changes, including:
    • Updated surveillance imaging frequency in several cancer types.
    • Added more robust information on radiotracers used in PET scans.
    • Added new section for Congenital Mesoblastic Nephroma (Pediatric only).
Policies Status Details
Administrative Policies
  • No updates for September 2018.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
The following pharmacy (drugs & biologics) coverage policies were modified effective September 15, 2018:
Chimeric Antigen Receptor T-Cell (CAR-T) and Advanced Cellular / Immune Effector Cell Therapy – (1808) New
  • Supports medical precertification.
Topical Doxepin – (P0054) New
  • Provides medical necessity criteria for generic and available brands.
Antiemetic Therapy (1705) Modified
  • Important changes in coverage criteria:
    • Added intravenous (IV) formulation of Akynzeo with interim criteria approved May 31, 2018.
    • Updated IV formulation of Akynzeo criteria as an option for use in moderately emetogenic chemotherapy.
    • Removed Anzemet (tablet formulation) and Varubi injectable criteria:
      • FDA lists both as discontinued.
        • Expanded Emend injectable criteria to include pediatric individuals six months and older as approved April 17, 2018.
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Modulators - (1207) Modified
  • Important changes in coverage criteria:
    • Removed list of gene mutations from stem:
      • Changed language to refer to a listing of the mutations “as specified in the product label”.
    • Added criteria already approved through interim criteria:
      • Revised age for Orkambi down to two years of age.
      • Added quantity limits for Kalydeco and Orkambi.
      • Added Symdeko criteria.
      • Revised age for Kalydeco down to 12 months of age.
    • Added Orkambi granules quantity limit.
Dose Optimization - (1804) Modified
  • Important changes in coverage criteria:
    • Removed Nexium 22.3mg and 44.6mg strengths.

Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List - (1601)

and

Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List - (1602)

Modified
Immunomodulators - (1805) Modified
  • Important changes in coverage criteria:
    • Modified Drug Removal Table criteria for:
      • Kineret
      • Siliq
      • Simponi
    • Added Entyvio as preferred brand for employer groups.
    • Expanded covered indications for:
      • Cimzia (plaque psoriasis)
      • Xeljanz/Xeljanz XR (ulcerative colitis)
        • Both have new indications in FDA labels.
Oncology Medications - (1403) Modified
Pegloticase – (1107) Modified
  • Important changes in coverage criteria:
    • Provided examples for contraindications per FDA label.
      • No change in intent to criteria.
Quantity Limitations - (1201) Modified
  • Important changes in coverage criteria:
    • Added previously approved quantity limits for doxepin and Lucemyra.
    • Modified proton pump inhibitors quantity limit to align with max adult daily dose language.
    • Added additional Helicobacter pylori authorization language for potential to exceed max adult daily dose limit.
Sacubitril-Valsartan - (P0016) Modified
  • Important changes in coverage criteria:
    • Consolidated/pared down bullets 1 and 2:
      • After re-evaluation of criteria due to high appeal overturn rates.
    • Removed New York Heart Association classification requirement.
    • Removed concomitant angiotensin-converting-enzyme inhibitor (ACE inhibitor)/angiotensin receptor blockers (ARBs) therapy statement.

Step Therapy - (1109) ,

Step Therapy – Standard Prescription Drug Lists (Employer Group Plans) - (1801),

Step Therapy – Value Prescription Drug Lists (Employer Group Plans) - (1802), and

Step Therapy – Legacy Prescription Drug Lists (Employer Group Plans) - (1803)

Modified
  • Important change in coverage criteria:
    • Added desoximetasone 0.25%spray (Topicort) to Step 1 Topical Inflammatory, High Potency.
Unassigned Drug or Biologic Code Medical Precertification - (1701) Modified
  • Important changes in coverage criteria:
    • Added criteria for Crysvita (burosumab-twza).
Viscosupplementation for Osteoarthritis - (1405) Modified
  • Important changes in coverage criteria:
    • Divided EIU statement into two statements:
      • Updated language in first statement to limit viscosupplement use to the knee only.
      • Address experimental use of a viscosupplement combined with any other intra-articular injection in second bullet.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • One policy updated for September 2018.
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
  • No updates for September 2018.

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.