Policy Updates October 2015

Highlights upcoming changes in existing policies, provides details on new policies, and lists retired policies. Contact Cigna Customer Service at 1.800.88Cigna (1.800.882.4462) for any questions.

Policies Status Details
Medical Coverage Policy
Drug Testing – (0513) New Establishes:
  • Medical necessity criteria for drug testing in a physician-supervised addiction or pain management treatment setting.
  • Daily and annual limits for drug testing frequency.
Genetic Testing for Hereditary Cancer Susceptibility Syndromes - (0518) New
  • Consolidates the content of five existing coverage policies
  • Is the first policy to be implemented in the redesign of genetic testing policies
  • Provides updated coverage criteria for colorectal cancer syndromes and hereditary breast and ovarian cancer
  • Adds coverage criteria for diffuse gastric cancer
  • Adds disease-specific coverage criteria for genetic testing for the following indications:
    • Juvenile Polyposis Syndrome
    • Peutz-Jeghers Syndrome
    • Cowden Syndrome/PTEN Hamartoma Tumor Syndrome
    • Li-Fraumeni Syndrome
Genetic Testing Collateral File New
  • This is not a coverage policy.
  • It is a new document to be used with coverage policies from our genetic testing coverage policy suite.
  • The document provides a list of specific genetic tests considered experimental, investigational or unproven (EIU), and also contains:
    • test name
    • laboratory performing the test
    • the associated Cigna coverage policy
    • the coverage position (i.e., EIU)
Autologous Platelet-Derived Growth Factors (Platelet-Rich Plasma [PRP]) - (0507) Modified Policy statement update with no change in coverage:
  • Added new code G0460 to existing not covered policy statement.
Benign Prostatic Hyperplasia (BPH) Treatments - (0159) Modified Policy statement update with no change in coverage:
  • Title changed from Benign Prostatic Hypertrophy (BPH) Treatments.
  • Changed "hypertrophy" to "hyperplasia" throughout the coverage policy.
  • Added new note to address pharmacological therapy for BPH.
Infertility Services - (0089) Modified Policy statement update with no change in coverage:
  • Clarified wording for sperm penetration assay and removed "for those with male factor infertility, who are considering IVF cycles and ICSI."
  • Added time-lapse monitoring to existing not covered policy statement.
Kidney Transplantation, Pancreas-Kidney Transplantation, and Pancreas Transplantation Alone - (0146) Modified Important changes in coverage:
  • Separated criteria for kidney transplantation from simultaneous pancreas-kidney transplantation.
  • The kidney criteria are now a standalone policy statement with less restrictive criteria.
  • Updated simultaneous pancreas-kidney transplantation criteria to be less restrictive.
Omnibus Codes - (0504) Modified Policy statement update with no change in coverage:
  • Added three not covered policy statements for services with unlisted codes.
    • Codes were represented by Category III codes, T codes, which were deleted in December 2013.
    • Codes were removed from the coverage policy in December 2014.
    • The services are now represented by unlisted codes.
  • Added code 0353T, which is a correction.
Topographic Genotyping - (0487) Modified Policy statement update with no change in coverage:
  • Title changed from Topographic Genotyping PathFinder TG® Test.
  • Name of test has changed to PancraGen.
Genetic Testing for Retinoblastoma – (0223) Retired The following policy has been retired effective October 15, 2015.
Now included in the Genetic Testing for Hereditary Cancer Susceptibility Syndromes – (0518).
Genetic Testing for RET Proto-Oncogene and Hereditary Paraganglioma- Pheochromocytoma (PGL/PCC) Syndrome – (0224) Retired The following policy has been retired effective October 15, 2015.
Now included in the Genetic Testing for Hereditary Cancer Susceptibility Syndromes – (0518).
Genetic Testing for Susceptibility to Breast and Ovarian Cancer (e.g., BRCA1 & BRCA2) – (0001) Retired The following policy has been retired effective October 15, 2015.
Now included in the Genetic Testing for Hereditary Cancer Susceptibility Syndromes – (0518).
Genetic Testing for Susceptibility to Colorectal Cancer – (0014) Retired The following policy has been retired effective October 15, 2015.
Now included in the Genetic Testing for Hereditary Cancer Susceptibility Syndromes – (0518).
Genetic Testing for von Hippel-Lindau Disease – (0334) Retired The following policy has been retired effective October 15, 2015.
Now included in the Genetic Testing for Hereditary Cancer Susceptibility Syndromes – (0518).
Observation Care - 0411 Retired The following policy has been retired effective October 15, 2015.
Policies Status Details
Pharmacy (Drugs, Vaccines, and Biologics) Policies
Interferon Therapy - (1315) Modified Important changes in coverage:
  • Addition of Peyronie's disease to the list of indications not covered.
Lysosomal Storage Disorders Therapy - (1319) Modified Important changes in coverage:
  • Title changed from Enzyme Replacement Therapy to reflect lysosomal storage disorder therapies.
  • Updated to add Miglustat criteria previously found in coverage policy 1317.
  • Clarified coverage criteria to not approve combination Gaucher Disease treatments.
Quantity Limitations - (1201) Modified Important changes in coverage:
  • Updated to include Zecuity® (sumatriptan iontophoretic transdermal system)
Rituximab (Rituxan) for Non-Oncology Indications - (5108) Modified Important changes in coverage:
  • Removed cyclophosphamide step from ANCA vasculitides based on FDA labeling and design of pivotal trial leading to FDA approval.
  • Removed “multicentric” from Castleman’s Disease based on National Comprehensive Cancer Network (NCCN) recommendations.
  • Added dermatomyositis and polymyositis to coverage with documented diagnosis (biopsy) criteria and failure of standard medical therapy.
Step Therapy - (1109) Modified Important changes in coverage:
  • Added new combination antidiabetic, Synjardy®, to Emerging Drug Step Therapy with same criteria as Jardiance®, FarxigaTM, Xigduo
  • Removed Androderm from step therapy, step one, criteria, used to satisfy requirements for non-preferred topical testosterone therapy.
Policies Status Details
Administrative Policies
Home Birth - (A002) Modified Clarified wording used to represent health care provider acting within the scope of his/her license or certification under the applicable state law.
CareAllies Medical Necessity Guidelines Modified Sixteen policies have been posted to the CareAllies Medical Necessity Guidelines.
Policies Status Details
Reimbursement Policies*
Omnibus Reimbursement Policy - (R24) Modified
    Important changes:
  • Updated to clarify intent of after-hours care policy.
  • Updated surgical trays policy section.
  • Updates are effective immediately.
Facility Routine Services, Supplies and Equipment - (R12) Modified Notification of examples of catheters not eligible for reimbursement expanded to include cardiac and vascular catheters, including guide wires used in percutaneous diagnostic studies and interventional procedures.
  • Edit will be effective December 1, 2015.
Policies Status Details
Claim Editing Policies and Procedures
Code Edit Policy and Guidelines Modified
  • Effective October 17, 2015, ClaimsXten facilitates accurate claim processing for medical and behavioral claims submitted on the Centers for Medicare and Medicaid Services (CMS) 1500 claim form and for certain claims submitted on a UB04 claim form.
  • On November 7, 2015 ClaimsXten will be updated to Fourth Quarter Knowledge Base content and NCCI Version 21.3 for all medical and behavioral claims we process.
Policies Status Details
Policies with a Reduction in Coverage**
Cardiac Rehabilitation (Phase II Outpatient) – (0073)
Cognitive Rehabilitation – (0124)
Intraocular Lens Implant (IOL) – (0125)
Pulmonary Rehabilitation – (0212)
Tilt Table Testing – (0066)
Modified Existing code editing (for claims billed on a CMS1500 form) will be applied to these five services when performed on an outpatient basis and billed on a UB-04 claim form.
Nerve Conduction Velocity (NCV) and Electromyography (EMG) – (0117) Two code edits will be applied. The first edit will screen NCV claims for medical necessity review. The second edit will help determine if a medically necessary NCV test can be performed alone without the EMG.
Affected CPT® codes include 95900, 95903, 95904, 95907, 95908, 95909, 95910, 95911, 95912, and 95913.
Obstructive Sleep Apnea (OSA) Diagnosis and Treatment (Home Portable Sleep Study) – (0158) Claims for home sleep studies billed in excess of one visit per 30 days will be denied.
Affected CPT® codes include 95800, 95801, 95806, and HCPCS codes G0398 and G0399.
Drug Testing – (0513) This update sets limits on both presumptive and definitive drug testing, including:
  • Presumptive Testing:a daily limit of 1 unit and a yearly limit of 32 units.
  • Definitive Testing:a daily limit of 8 units and a yearly limit of 128 units.
Drug Testing Billing Requirements reimbursement policy (R25) CMS does not recognize Healthcare Common Procedure Coding System (HCPCS) codes H0003 and H0049 as valid codes for drug screening; therefore, we will no longer cover either code.
We are aligning with CMS to require the use of HCPCS codes G0431 and G0434 as the appropriate codes to bill for drug screen services.

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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** The following policy updates, effective October 19, 2015, will result in a reduction of coverage.