Policy Updates November 2015

Policies Status Details
Medical Coverage Policy
Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias – (0517) New
  • Includes existing content/policy statement for genetic testing for Long QT syndrome from the Genetic Testing for Long QT Syndrome (coverage policy 0192) coverage policy, which was retired on November 15, 2015.
  • Genetic counseling still required before genetic testing for Long QT syndrome is done.
  • Important changes in coverage:
    • Added new policy statement for coverage of known familial mutation analysis for Brugada syndrome
  • Policy statement updates with no change in coverage:
    • Added new policy statement for coverage of single gene genetic testing for dilated cardiomyopathy.
    • Added new policy statement for coverage of known familial mutation analysis for several cardiac diagnoses.
    • Added new not covered policy statement for genetic testing for short QT
    • Added new not covered policy statement for genetic testing for broad multicondition panel testing.
    • Added new not covered policy statement for genetic testing for hereditary cardiac conditions in the general population.
  • Unknown if change in coverage:
    • Added new not covered policy statement for genetic testing for atrial fibrillation
Whole Exome and Whole Genome Sequencing – (0519) New
  • Policy statement updates, unknown if change in coverage:
    • Added new policy statement for whole exome sequencing if criteria in the coverage policy are met.
    • Added new policy statement for comparator exome sequence analysis.
    • Added new not covered policy statement for whole exome sequencing for prenatal diagnosis or preimplantation testing of an embryo
    • Added new not covered policy statement for whole exome sequencing testing in the general population.
  • Policy statement updates with no change in coverage:
    • Added new genetic counseling policy statement.
    • Added not covered policy statement for whole genome sequencing for any indication.
Breast Reconstruction Following Mastectomy or Lumpectomy - (0178) Modified
  • Policy statement updates effective November 15, 2015 with no change in coverage:
    • Added policy statement addressing intraoperative assessment of tissue perfusion.
    • Edited superficial inferior epigastric perforator bullet point.
  • Important change in coverage, effective February 15, 2016:
    • Moved SurgiMend® from covered to not covered.
Electrical Stimulation Therapy and Devices - (0160) Modified
  • Advance health care professional notification previously done on August 15, 2015 for changes effective November 15, 2015.
  • Important changes in coverage:
    • Added "and related supplies (HCPCS Code A4595)" to the covered and not covered policy statements for neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulator (TENS).
    • This is a change from covered to not covered
      • Cigna will no longer pay for A4595 if not billed with an approved TENS unit or NMES device.
Genetic Testing of Heritable Disorders - (0052) Modified
  • Important change in coverage:
    • Added policy statement for coverage of genetic testing for alpha 1 antitrypsin deficiency.
  • Policy statement updates with no change in coverage:
Obstructive Sleep Apnea Diagnosis and Treatment Services – (0158) Modified
  • Policy statement updates with no change in coverage:
    • Updated numerous policy statements to clarify intent.
    • Updated pediatric in-facility polysomnography (PSG) policy statement to address possible central sleep apnea in an infant with cardiac history.
    • Added policy statement in the "Other Diagnostic Tests" to address multiple sleep latency testing (MSLT).
    • Renamed Home Sleep Testing (HST) to Home Sleep Apnea Testing (HSAT).
    • Added policy statement addressing coverage of Auto Bilevel therapy.
    • Added note defining positive airway pressure (PAP) adherence to PAP Adherence policy statement.
    • Removed policy statement about expiratory pressure relief settings.
    • Added policy statement about non-coverage of the MATRx remote- controlled oral appliance titration study.
    • Added bullet point to the "Additional Procedures/Services EIU" policy statement about electrical devices used as therapy for positional obstructive sleep apnea.
Physical Therapy – (0096) Modified
    Policy statement update with no change in coverage:
    • Added scoliosis to existing not covered policy statement.
Prosthetic Devices: Upper Limb Myoelectric – (0233) Modified
  • Policy statement update with no change in coverage:
    • Clarified wording in disclaimer about power enhancements/controls.
    • Added disclaimer stating components and/or additions to upper limb myoelectric devices may require separate medical necessity review.
Screening Mammography – (0123) Modified
  • Policy statement updates effective November 15, 2015 with no change in coverage:
    • Changed scope of coverage policy to address only screening mammography.
    • Changed title from Mammography to Screening Mammography
    • Removed policy statements for diagnostic mammography, surveillance mammography, digital image and computer-aided detection.
  • Important change in coverage, effective February 15, 2016:
    • Screening 3D mammography (also known as digital breast tomosynthesis [DBT]) will be denied.
Tissue-Engineered Skin Substitutes – (0068) Modified
  • Policy statement updates effective November 15, 2015 with no change in coverage:
    • Added 20 new products to existing not covered policy statement
  • Important change in coverage, effective February 15, 2016:
    • Moved SurgiMend® from covered to not covered.
Varicose Vein Treatments – (0234) Modified
  • Policy statement update with no change in coverage:
    • Added a new treatment to existing not covered policy statement.
Genetic Testing for Long QT Syndrome (LTQS) – 0193 Retired Content is now included in the new Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias – (0517).
Emerging Breast Localization/Biopsy Procedures - coverage policy 0205 Retired The Emerging Breast Localization/Biopsy Procedures - coverage policy 0205 was retired effective November 15, 2015.
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Lumicaftor/Ivacaftor (Orkambi™) - (1508) New
  • Orkambi is a newly FDA approved combination therapy, which combines Ivacaftor with a new medication, Lumicaftor, to treat cystic fibrosis.
    • Coverage policy supports Pharmacy Specialty Prior Authorization program requirements.
Botulinum Therapy - (1106) Modified
  • Important changes in coverage:
    • Added chronic migraine criteria:
      • Requires that pre-requisite medications must come from different classes of medications approved for migraine prophylaxis.
    • Updated criteria for re-authorization for treating chronic migraine headaches.
Oncology Medications - (1403) Modified
  • Important changes in coverage:
    • Added newly FDA approved oncology medication, trifluridine/ tipiracil (Lonsurf), to the Oncology Medication Pharmacy Benefit table
    • Added Siltuximab (Sylvant) to the Oncology Medication Medical Benefit table.
    • Retired stand-alone Siltuximab coverage policy 1411.
Pharmacy Prior Authorization – (1407) Modified
  • Important changes in coverage:
    • Added Dalfampridine (Ampyra) for use in multiple sclerosis, no change in criteria.
    • Retired stand-alone Dalfampridine (Ampyra) coverage policy 1022.
Quantity Limitations – (1201) Modified
  • Important changes in coverage:
    • Updated to include newly FDA approved cancer antiemetic, Varubi (rolapitant)
    • Quantity limits consistent with FDA recommended dosing.
Step Therapy - (1109) Modified
  • Important changes in coverage:
    • Updated to include new generic available, paliperidone (step 1)
    • Updated to include new brand strength available for Versacloz (step 3) under Global Step Therapy/Atypical Antipsychotics.
Dalfampridine (Amprya®) - 1022 Retired
Siltuximab (Sylvant) - 1411 Retired
Policies Status Details
Administrative Policies
No administrative policies were modified in November.
Policies Status Details
CareAllies Medical Necessity Guidelines
Updates Twenty policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).
Policies Status Details
Reimbursement Policies*
R24 Omnibus Reimbursement Policy Modified
  • Important changes:
    • Updated codes in surgical tray section.
HCPCS Modifier Policy – MHCPCS Modified
  • Important changes:
    • Added modifiers EX, L1, PO, and S2 as informational.
    • Added modifiers XE, XP, XS, XU as impacting reimbursement.
R17 - Laboratory Services Modified
  • Important changes:
Modifier 62, 66, 80, 81, 82, AS - Policy MAS Modified
  • Important changes:
    • Added Certified Registered Nurse First Assistant (CRNFA) to list of credentials for Assistant at Surgery.
Policies Status Details
Claim Editing Policies and Procedures Modified ClaimsXten Documents
Code Edit Bulletin - January 2016 New
  • Important changes effective January 4, 2016:
    • ClaimsXten will be updated to recognize Place of Service (POS) 19.
    • Claims submitted with POS 19 will process in ClaimsXten in the same manner as POS 22.

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.

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