Policy Updates September 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 Status Update to Coverage
Policies With a Reduction in Coverage
We are changing how we reimburse for the following policies:

Some medical coverage policies will expand to apply outpatient UB-04 claim forms

Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective September 15, 2019:
Home Ventilators – (0546) New
  • Advance notification of policy effective January 1, 2020:
    • Code E0466 will be added to precertification.
      • Code E0467 already on precertification.
      • Code E0465 does not require precertification.
Fecal Bacteriotherapy (Fecal Microbiota Transplantation) - (0516) Modified
  • Minor changes in coverage criteria/policy:
    • Clarified existing policy statement on diagnostic testing.
Metatarsophalangeal Joint Replacement - (0446) Modified
  • Important change in coverage criteria::
    • Added synthetic cartilage Implant (e.g., Cartiva® Synthetic Cartilage Implant) to existing experimental, investigational, unproven (EIU) policy statement.

Minimally Invasive Spine Surgery Procedures and Trigger Point Injections – (0139)

Modified
  • Important changes in coverage criteria:
    • Added policy statement for coverage of single-level lumbar endoscopic decompression.
    • Added cervical microdecompression surgery (Jho Procedure):
    • Added Barricaid® (annular device) to existing EIU policy statement.
  • Additional change effective November 15, 2019:
    • Title change from “Minimally Invasive Intradiscal/Annular Procedures and Trigger Point Injections” to title noted above.
Nutritional Support – (0136) Modified
  • Important changes in coverage criteria:
    • Updated banked breast milk policy statement to allow for coverage of banked breast milk for hospitalized infants in the neonatal intensive care unit (NICU).
Transthoracic Echocardiography in Adults - (0510) Modified
  • Minor changesin coverage criteria/policy:
    • Reorganized long policy statement into table format.
    • Clarified/corrected hypertension verbiage.

Hallux Valgus Surgery (Bunionectomy) – (0304)

Hammer Toe Surgery – (0305)

Retired
  • No longer have business value; therefore, will no longer be maintained.
Policies Status Details
Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Updated Electrodiagnostic Testing (EMG/NCV) - (CPG 129)
  • No change in coverage.
Updated Spinal Ultrasound – (CPG 038)
  • Added and clarified policy statement criteria.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
New Advance notification of two new Cigna-eviCore Cobranded Gastrointestinal Endoscopic Procedures guidelines, posting October 1, 2019, effective January 1, 2020:
  • Esophagogastroduodenoscopy (EGD).
  • Capsule Endoscopy
    • Will retire existing policy Capsule Endoscopy – (0008) on December 31, 2019
Policies Status Details
Administrative Policies
  • No updates for September 2019.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following medical coverage policies were modified effective September 1, 2019:
Antiparkinson Agents - (P0006) Modified
  • Important changes in coverage criteria:
    • Updated and retitled incorporating the Gocovri, Lodosyn, Requip XL and Zelapar preferred therapy criteria.
      • Previous title was Apomorphine - (P0006).
    • Added Osmolex ER as prerequisite option for Gocovri.
    • Added Inbrija criteria.
    • Added initial and reauthorization interval limits.
Dalfampridine - (P0004) Modified
  • Important changes in coverage criteria:
    • Added age restriction, aligned to FDA-labeled indication.
    • Excluded concurrent use with other potassium channel blockers.
    • Added requirement for recipient to be ambulatory.
    • Excluded use in wheelchair-bound individuals.
    • Added initial and reauthorization time limits of 12 months and reauthorization criteria.
Oncology Medications - (1403) Modified
  • Minor changes in coverage criteria:
Rituximab for Non-Oncology Indications – (5108) Modified
  • Important changes in coverage criteria:
    • Added requirement of first-line use treatment with intravenous immunoglobulin, anti-D immunoglobulin, corticosteroid, or splenectomy due to support from the American Society of Hematology (ASH) evidence-based guideline for immune thrombocytopenia for immune or idiopathic thrombocytopenia (ITP) (2011).
    • Added criteria for off-label use for myasthenia gravis after failure of two immunosuppressive agents due to compendia and clinical trial support.
    • Added criteria for off-label use for Sjogren’s syndrome based on American College of Rheumatology (ACR) and Sjogren’s syndrome foundation joint treatment guidelines for rheumatologic manifestations of Sjogren’s syndrome (2017).
    • Added criteria for off-label use for systemic lupus erythematous in individuals with neuropsychiatric manifestations and those with lupus nephritis after failure of one immunosuppressive agent due to guideline support from European League Against Rheumatism (EULAR) recommendations for the management of systemic lupus erythematosus with neuropsychiatric manifestations, Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR-EDTA) (2012), and the ACR guidelines for screening, treatment, and management of lupus nephritis (2012).
    • Added authorization and reauthorization timeframes for 12 months and for continued use the initial criteria must be met.
    • Added chronic inflammatory demyelinating polyneuropathy (CIDP), pediatric acute-onset neuropsychiatric syndrome/pediatric autoimmune neuropsychiatric disorders (PANS/PANDAS), and IgG4-related disease (immunoglobulin G4) due to lack of substantial clinical information for these diagnosis to the EIU section.
Valbenazine - (P0020) Modified
  • Important changes in coverage criteria:
    • Added requirement for Ingrezza to be prescribed by a neurologist or a psychiatrist.
    • Added requirement for individual to have history of dopamine receptor blocking agent therapy.
    • Incorporated criteria for Ingrezza Therapy Pack where coverage for the Therapy Pack will be limited to treatment initiation.
    • Added initial and reauthorization time limits of 12 months and reauthorization criteria.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for September 2019
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
Code Edit and Policy Guidelines
  • No updates for September 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.