Policy Updates September 2020

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
We are changing how we reimburse for the following policies:
There were no additional changes made in September 2020 that resulted in a reduction in coverage.
Policies Status Details
Medical Coverage Policies
  • Unless otherwise noted, the following medical coverage policies were modified effective September 15, 2020:
  • Please note – Going forward, as medical coverage policies are created and/or updated, we will include expanded Medicare information in each policy. Users can link to the Medicare policy table from the table of contents contained in each coverage policy.
Site of Care: Outpatient Hospital for Select Musculoskeletal Procedures – (0553) New
  • Advance notification of new policy, effective April 2, 2021:
    • eviCore to redirect inpatient musculoskeletal services to outpatient sites.
Cardiac Rehabilitation (Phase II Outpatient) - (0073) Modified
  • Important changes in coverage criteria, posted and effective August 15, 2020:
    • Removed policy statement addressing cardiac rehabilitation programs without electrocardiographic (ECG) monitored sessions.
    • Added five qualifying events for cardiac rehabilitation.
    • Added phase II cardiac rehabilitation program requirements.
    • Removed requirement of qualifying formal exercise stress test.
    • Added policy statement addressing outpatient intensive cardiac rehabilitation programs considered educational and training in nature.
Cryounits/Coooling Devices - (0314) Modified
Electrical Stimulation Therapy and Home Devices - (0160) Modified
  • Important change in coverage criteria:
    • Updated HCPCS code for cranial electrical stimulation.
      • Implementing new code K1002 via always experimental, investigational, or unproven (EIU) edit.
Implantable Electrocardiographic Event Monitors - (0547) Modified
  • Important change in coverage criteria:
    • Added new policy statement that implantable loop recorder (ILR) is considered EIU for any other indication.
Nutritional Support - (0136) Modified
  • Important changes in coverage criteria:
    • Clarified benefit disclaimer verbiage.
    • Added new policy statement for digestive enzyme cartridge (e.g., Relizorb).
Phototherapy, Photochemotherapy, and Excimer Laser Therapy for Dermatologic Conditions - (0031) Modified
  • Important changes in coverage criteria:
    • Added policy statements allowing coverage of vitiligo for phototherapy and excimer laser.
Screening Mammography – (0123) Retired
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
Updated Electrodiagnostic Testing (EMG/NCV) – (CPG 129) Modified
  • Minor changes for clarification.
Updated Spinal Ultrasound – (CPG 038) Modified
  • No change in criteria.
Policies Status Details
Cigna-eviCore Cobranded Guidelines
High-Tech Radiology (HTR or Imaging) guidelines Modified
  • Important changes, effective October 1, 2020:
    • Updated imaging guidelines for Chest Adult:
      • Added new section 13.2: Coronavirus Disease (COVID-19), which addresses chest CT.
Radiation Oncology guidelines Modified
  • Important changes, effective September 24, 2020:
    • Updated Radiation Therapy guidelines, which includes:
      • Breast Cancer:
        • Changes made in fractionation for whole breast irradiation following breast-conserving surgery.
      • Prostate Cancer:
        • Removed 3DCRT coverage for definitive treatment of low- and intermediate-risk disease.
Policies Status Details
Administrative Policies

Custodial and Non-Skilled Services – (A012)

Long Term Care Hospitals (LTCH) – (A011)

New
  • New policies, effective September 1, 2020.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective September 1, 2020:
Cyanocobalamin Nasal Spray - (P0097) New
  • Supports medical necessity requirements, effective September 14, 2020.
Antihyperglycemic Therapy (Non-Insulin) – (P0098) Modified
  • Minor changes in coverage criteria/policy:
    • Added criteria for Trijardy XR consistent with preferred brand designation:
      • The “metformin first” prerequisite criteria for use is still required.
Compounded Medications - (1406) Modified
  • Minor changes in coverage criteria/policy, effective September 15, 2020:
    • Added clarifying comment that compound contains only human, pharmaceutical-grade ingredients.
Opioid Therapy - (1704) Modified
  • Important changes in coverage criteria:
    • Removed Arymo ER, Exalgo and Opana ER from extended-release opioid analgesic products table.
    • Incorporated tramadol 100 mg tablet criteria located in criteria manual.
    • Modified opioid therapy management agreement statement to only require the signature of the individual being treated.

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

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

Step Therapy - Legacy Group Plan (Employer Group Plans) - (1803)

Modified
  • Minor changes in coverage criteria/policy:
    • Added Trijardy XR (diabetic medication) to metformin-first step therapy program:
      • Responsive to business decision.
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for September 2020
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Policies Status Details
ClaimsXten*
  • No updates for September 2020.

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.