Cigna Clinical, Reimbursement, and Administrative Policy Updates

March 2019 ~

Cigna has published a number of clinical, reimbursement, and administrative policy updates, including its reimbursement policy for diagnostic microbe testing and diabetes equipment and self-management.

Policies with a Reduction in Coverage

Policy: Diagnostic Microbe Testing for Sexually Transmitted Diseases (STDs) – (0530)

Update: Cigna will implement a new medical coverage policy, Diagnostic Microbe Testing for Sexually Transmitted Diseases (STDs) (0530), to review tests for medical necessity.

  • Please note that this policy does not affect STD testing that is covered as a preventive benefit when billed with a wellness diagnosis. Additionally, medical necessity review is not required when STD testing is for patients’ ages two and under, or when billed with a pregnancy diagnosis.
  • This policy is effective for dates of service beginning February 18, 2019.

Policy: National Correct Coding Initiatives (NCCI) for Facilities Reimbursement Policy – (R09)

Update: Cigna will expand the list in its current National Correct Coding Initiatives (NCCI) for Facilities Reimbursement Policy (R09) to include industry-standard column one and column two procedure-to-procedure (PTP) codes where at least one of the codes is for an evaluation and management (E&M) visit in an emergency room when billed with another service. Cigna will deny either the E&M or the other service as not separately reimbursable.

  • This update affects claims from outpatient facilities processed on or after February 18, 2019.

Medical Coverage Policies

Unless otherwise noted, the following medical coverage policies were modified effective February 15, 2019:

Policy: Diagnostic Microbe Testing for Sexually Transmitted Diseases (STD) – (0530)

Status: New

Update: Advance notification originally provided on November 15, 2018, for policy effective February 15, 2019:

  • Identifies medically necessary ICD10 codes/CPT® code pairs for diagnostic microbe testing for:
    • Chlamydia
    • Gardnerella
    • Genital Herpes (Herpes Simplex Virus Types 1 and 2)
    • Gonorrhea (Neisseria gonorrhea)
    • Human Papillomavirus (HPV)
    • High-risk types (e.g., types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)
    • Invasive Candidiasis
    • Candidemia
    • Trichomonas
    • Syphilis
  • Reflects that molecular testing is not medically necessary for:
    • Noninvasive or mucosal candidiasis (e.g., vaginal candidiasis)
    • HPV
    • Low-risk types (e.g., types 6, 11, 42, 43, 44)
    • Syphilis
  • Includes reimbursement note that use of “not otherwise specified” codes is not reimbursable when a more specific code is available.

Policy: Breast Implant Removal – (0048)

Status: Modified

Update: Important change in coverage criteria:

  • Added breast implant removal for diagnosed breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Policy: Breast Reconstruction Following Mastectomy or Lumpectomy – (0178)

Status: Modified

Update: Important changes in coverage criteria:

  • Added four products to existing experimental, investigational or Unproven (EIU) policy statement:
    • ARTIA™ Reconstructive Tissue Matrix
    • BellaDerm® Acellular Hydrated Dermis
    • GalaFLEX® Surgical Scaffold/Mesh
    • GalaFORM™ 3D
  • Removed reference to “vascularized lymph node transfer (VLNTx)”.
    • Information in Surgical Treatments for Lymphedema and Lipedema – (0531).

Policy: Diabetes Equipment and Self-Management – (0106)

Status: Modified

Update: Important changes in coverage criteria:

  • Changed title from “Home Blood Glucose Monitors to Diabetes Equipment and Self-Management”.
    • Combined information from the following three policies being retired:
    • Diabetes Self-Management – (0413)
    • Diabetic Supplies – (0126)
    • External Insulin Pumps – (0087)
  • Updated policy statement for glucose monitors and diabetes supplies:
    • differentiated between non-therapeutic and therapeutic continuous glucose monitors (CGMs) and updated language.

Policy: Drug Testing – (0513)

Status: Modified

Update: Important changes in coverage criteria:

  • Deleted bullet about specimen verification:
    • Information will be included in the Laboratory Services – (R17) reimbursement policy.
  • Added note that specimen verification is part of the quality assurance process and not separately reimbursable.

Policy: Exhaled Nitric Oxide in the Management of Respiratory Disorders – (0439)

Status: Modified

Update: Important changes in coverage criteria:

  • Changed title from “Exhaled Nitric Oxide and Exhaled Breath Condensate in the Management of Respiratory Disorders”.
  • Removed “Breath Condensate” wording from the policy.

Policy: Omnibus Codes – (0504)

Status: Modified

Update: Important changes in coverage criteria:

  • Reviewed non-FDA services – all remain EIU.
  • Added one EIU service that has recent FDA approval to the OB/GYN section:
    • Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency.
  • Added section for percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve).
    • Remains EIU.

Policy: Plantar Fasciitis Treatments – (0097)

Status: Modified

Update: Important change in coverage criteria:

  • Removed acupuncture from existing EIU policy statement.
    • Addressed in Cigna-American Specialty Health (ASH) cobranded Clinical Practice Guidelines (CPG) Acupuncture – (CPG 024)

Policy: Tissue-Engineered Skin Substitutes – (0068)

Status: Modified

Update: Important changes in coverage criteria:

  • Increased number of covered Grafix applications from four to six.
  • Added 36 new products added to existing EIU policy statement.

Policy: Biofeedback – (0166)

Status: Retired

Update: Added content to new cobranded Cigna ASH CPG Biofeedback – (CPG 294)

Policy: Computerized Electrocardiograph (ECG) Analysis – (0210)

Status: Retired

Update: Being retired on February 19, 2019.

Policy: Mechanical Devices for the Treatment of Back Pain – (0140)

Status: Retired

Update: Added gravity assisted traction and code E0941 to Home Traction Devices – Cervical and Lumbar – (CPG 265)

Policy: Pulsed Electromagnetic Therapy – (0236)

Status: Retired

Update: Being retired on February 19, 2019

Policy: Three policies being retired with content added to Diabetes Equipment and Self-Management – (0106)

Status: Retired

Update: Being retired on February 19, 2019

  • Diabetes Self-Management – (0413)
  • Diabetic Supplies – (0126)
  • External Insulin Pumps – (0087)

Cigna-American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGS)

Policy: Biofeedback – (CPG 294)

Status: New

Update: Added content from retired medical coverage policy Biofeedback – (0166).

  • Additional covered conditions include fecal incontinence, stroke, and refractory levator ani syndrome.

Policy: Home Traction Devices – Cervical and Lumbar – (CPG 265)

Status: Modified

Update: Important changes:

  • Added gravity-assisted traction from retired medical coverage policy Mechanical Devices for the Treatment of Back Pain – (0140).

Cigna-eviCore Cobranded Guidelines

Policy: Updated Cigna-eviCore Cobranded High-Tech Radiology Therapy Guidelines for breast imaging effective January 29, 2019

Status: Modified

Update: Added computer-aided detection (CAD) for breast magnetic resonance imaging (MRI).

  • Remains EIU.

Policy: Updated the following Comprehensive Musculoskeletal Management Guidelines

Status: Modified

Update:

  • Sacroiliac (SI) Joint Injections – (CMM 203)
    • Added sacral lateral nerve branch blocks as EIU for SI joint pain.
    • Moved SI joint pain diagnosis criteria from general information section to indications section.
      • No change to intent of coverage/implementation.
    • Clarified criteria for diagnostic versus therapeutic repeat injection.
  • Spinal Cord and Dorsal Root Ganglion Stimulation – (CMM 211)
    • Changed title from “Spinal Cord and Implanted Peripheral Nerve Stimulation”.

Administrative Policies

No updates for February 2019.

Pharmacy (Drugs & Biologics) Policies

Unless otherwise noted, the following drug and biologic coverage policies were modified effective March 1, 2019:

Policy: Avatrombopag – (P0079)

Status: New

Update: Supports pharmacy prior authorization.

Policy: Fostamatinib – (P0081)

Status: New

Update: Supports pharmacy prior authorization.

Policy: Hereditary Transthyretin Amyloidosis Agents – (1901)

Status: New

Update: Supports medical precertification for Onpattro (patisiran).

  • Supports pharmacy prior authorization for Tegsedi (inotersen).

Policy: Ibalizumab-uiyk – (M0001)

Status: New  

Update: Supports medical precertification.

Policy: Lusutrombopag – (P0080)

Status: New

Update: Supports pharmacy prior authorization.

Policy: Cerliponase alfa – (1807)

Status: Modified

Update: Important changes in coverage criteria:

  • Modified genetic testing with specific “biallelic pathogenic or likely pathogenic variants in the TPP1 gene”.
  • Modified the medically necessary statement to include that the individual be symptomatic.

Policy: Denosumab – (1212)

Status: Modified

Update: Important changes in coverage criteria:

  • Added criteria for treatment of glucocorticoid-induced osteoporosis.
  • Modified criteria for treatment of giant cell tumor of bone for Xgeva.
  • Added concomitant use with bisphosphonate as an EIU use.
  • Added thalassemia-induced osteoporosis as an EIU use in those individuals who do not meet the osteoporosis coverage.
  • Added initial authorization up to 12 months.

Policy: Dimercaprol and Edetate Calcium Disodium – (6019)

Status: Modified

Update: Important changes in coverage criteria:

  • Expanded the EIU statement to add other heavy metal poisoning.

Policy: Hepatitis C Therapy – (1316)

Status: Modified

Update: Important changes in coverage criteria:

  • Added authorized generics as preferred products for Employer Groups.
  • Brand products remain preferred products for Individual and Family Plans.

Policy: Implantable Hormone Pellets – (1504)

Status: Modified

Update: Important changes in coverage criteria:

  • Modified laboratory values that define low testosterone levels.
  • Added a “male” bullet for hypogonadism/hypogonadotropic hypogonadism and delay in puberty criteria for Testopel (testosterone pellets).
  • Revised the EIU section by removing the treatment of menopausal symptoms for Testopel and adding use in females for any indication.
  • Added reauthorization criteria:
    • Must have met all criteria for initial therapy and documentation of “positive clinical response”.

Policy: Modafinil/Armodafinil – (1501)

Status: Modified

Update: Important changes in coverage criteria:

  • Added age restriction aligned to the FDA label of both products.
  • Streamlined the obstructive sleep apnea/hypopnea syndrome indication statement.
  • Streamlined the Parkinson’s disease excessive daytime sleepiness (EDS), without changing the criteria intent.
  • Added initial and reauthorization criteria.

Policy: Oncology Medications – (1403)

Status: Modified

Update: Important change in coverage criteria:

  • Added Khapzory to specific additional criteria table.

Policy: Oral Phosphodiesterase-5 (PDE5) Inhibitors – (7003)

Status: Modified

Update: Important change in coverage criteria:

  • Updated criteria stem to reflect new Staxyn generic.

Policy: Repository Corticotropin – (8001)

Status: Modified

Update: Important changes in coverage criteria:

  • Added statement incorporating updated version of the less costly alternative language found in the background:
    • No change to criteria intent.
  • Added initial and reauthorization criteria.

Policy: Step Therapy (Global) – (1109)

Status: Modified

Update: Important changes in coverage criteria:

  • Removed Belbuca.

Policy: Step Therapy – Standard and Performance PDLs (Employer Group Plans) – (1801) and Step Therapy – Value and Advantage PDLs (Employer Group Plans) – (1802) and Step Therapy – Legacy Group Plan (Employer Group Plans) – (1803)

Status: Modified

Update: Important changes in coverage criteria:

  • Added new strength (160 mg) of nanocrystallized fenobfibrate to Fibrates – Standard Dose Step 1 list.

 Policy: Tasimelteon – (P0018)

Status: Modified

Update: Important changes in coverage criteria:

  • Added age restriction aligned to the inclusion criteria from pivotal trials (SET and RESET).
  • Added initial and reauthorization criteria.

Policy: Quantity Limitations – (1201)

Status: Modified

Update: Important changes in coverage criteria:

  • Added quantity limits for oral PDE5 inhibitors for Individual and Family Precription Drug Plan benefit reference.
  • Added budesonide (Uceris).

CareAllies Medical Necessity Guidelines

Update: One policy updated for February 2019.

Precertification Policies

No updates for February 2019.

Reimbursement Policies

Update: Updated two reimbursement policies:

  • Facility Routine Services, Suppliers, and Equipment – (R12)
  • Healthcare Common Procedure Coding System (HCPCS) National Level II Modifiers

CLAIMSXTEN

Policy: Code Edit Bulletin (March 2019)

Status: Important changes effective March 17, 2019:

Update: To better align with CMS, Cigna is implementing Medically Unlikely Edits (MUE) for CPT® codes 88300-88309, 90791-90792 and 90832-90839.

 

CPT® is a registered trademark of the American Medical Association.

 

Source(s): Cigna;

 

 

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