Cigna Clinical, Reimbursement, and Administrative Policy Updates

August 2019 ~

Cigna has published a number of clinical, reimbursement, and administrative policy updates, including its reimbursement policy for spinal fusion related services, venous angioplasty, and orthotic prescriptions. These updates can be seen below.

Procedure/Policy: Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery (0481)

Effective Date: for claims with dates of service on or after August 19, 2019.

Update: In alignment with Cigna’s current medical coverage policy, Drug-Eluting Devices for Use Following Endoscopic Sinus Surgery (0481), the insurer will deny claims for drug-eluting stents following sinus surgery as being experimental, investigational, and unproven (EIU).

The affected Healthcare Common Procedure Coding System (HCPCS) codes are C1874, C1875, C1876, C1877, C2617, and C2625.

Procedure/Policy: Orthotic Prescriptions with No Evaluation

Effective Date: for claims with dates of service on or after August 19, 2019.

Update: Cigna will implement a new medical coverage policy, Orthotic Devices and Shoes (0543), and deny claims billed for orthotic prescriptions costing $250 or greater as not medically necessary if the referring provider did not conduct an in-person evaluation of the patient within six months before the date of service.

Additionally, claims that do not include a referring provider will be pended for additional information.

This update applies to spine, knee, and lower and upper limb orthotic devices.

The new policy will replace the following existing policies:

› Cranial Orthotic Devices for Positional and Deformational Plagiocephaly (0056)

› Lower Limb Orthoses and Shoes (0150)

› Myoelectric Devices: Upper Limb (0233)

› Knee Braces (0362)

› Spinal Orthoses (0394)

Procedure/Policy: Vitamin D Testing (0526)

Effective Date: for claims with dates of service on or after August 19, 2019.

Update: Cigna will update its current medical coverage policy, Vitamin D Testing (0526), to add a frequency limit of two lab tests in a 365-day rolling period for claims billed with Current Procedural Terminology (CPT®) code 82306 (Vitamin D; 25 Hydroxy).

This frequency limit does not apply to vitamin D testing for chronic kidney disease and malabsorption syndromes.

This does not affect other terms the policy regarding vitamin D testing, including coverage for routine vitamin D screening. Cigna will also limit testing per date of service to one code. As such, claims billed with CPT® code 82652 (Vitamin D; 1, 25 Dihydroxy) in combination with CPT® code 82306, will be denied and marked as duplicative.

Procedure/Policy: Spinal Fusion-Related Services

Effective Date: for claims with dates of service on or after August 23, 2019.

Update: Cigna will update three coverage policies to require precertification for spinal fusion-related codes. The insurer will review these codes under the precertification requirements for the primary procedure.

The affected medical coverage policies are Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, including Sacroiliac Fusion (0303), Cervical Fusion (0527), and Bone, Cartilage and Ligament Graft Substitutes (0118).

Procedure/Policy: Venous Angioplasty With or Without Stent Placement for Adults (0541)

Effective Date: for claims with dates of service on or after August 23, 2019.

Update: Cigna will update its current medical coverage policy, Venous Angioplasty With or Without Stent Placement for Adults (0541), to require precertification.

This policy affects adults age 18 and older.

The affected CPT® codes are 37238, 37239, 37248, and 37249.

Procedure/Policy: Some Medical Coverage Policies Scheduled to Expand

Effective Date: for claims with dates of service on or after September 16, 2019.

Update: Cigna will expand the medical coverage policies listed below so that they will also apply to outpatient claims submitted on UB-04 claim forms.

› Acupuncture – (CPG024)

› Allergy Testing and Non-Pharmacologic Treatment – (0070)

› Autonomic Nerve Function Testing – (0506)

› Biofeedback – (CPG294)

› Dermabrasion and Chemical Peels – (0505)

› Electrical Stimulation Therapy and Home Devices – (0160)

› Electrodiagnostic Testing (EMG/NCV) – (CPG129)

› Electroencephalography – (0521)

› Gait Analysis – (0315)

› Plasma Brain Natriuretic Peptide in the Outpatient Setting – (0028)

› Spinal Ultrasound – (CPG038) › Strapping and Taping – (CPG143)

› Transvaginal Ultrasound, Non-Obstetrical – (0398)

› Wheelchairs/Power Operated Vehicles – (0030)

 

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

 

 

Source(s): Cigna Network News, July 2019;

 

 

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