Cigna Clinical, Reimbursement, and Administrative Policy Updates

November 2019 ~

Cigna has released its latest clinical, reimbursement, and administrative policy updates, including medical policy, medical benefit drug policy & coverage determination guideline updates.

These recent policy updates can be seen below.

Policies with a Reduction in Coverage

Policy: Evaluation and Management (R30)

Effective: claims processed beginning October 19, 2019

Update: Cigna will implement a new reimbursement policy, Evaluation and Management (R30), and deny claims billed with Current Procedural Terminology (CPT®) consultation codes as not valid.

  • The affected CPT codes are 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, and 99255.

Policy: Scrotal Ultrasound (0548) and Head and Neck Ultrasound (0549)

Effective: dates of service beginning October 21, 2019

Update: Cigna will implement two new medical coverage policies, Scrotal Ultrasound (0548) and Head and Neck Ultrasound (0549), and apply medical necessity criteria for scrotal ultrasounds and head and neck ultrasounds.

  • The affected CPT codes are 76536 and 76870.

Policy: Angioplasty (Extracranial, Intracranial) and Endoluminal Flow Diverting Stents (0545)

Effective: October 15, 2019

Update: Cigna will implement a new medical coverage policy, Angioplasty (Extracranial, Intracranial) and Endoluminal Flow Diverting Stents (0545), and require precertification for extracranial and intracranial angioplasty and endoluminal flow diversion procedures. The insurer will review for medical necessity of the procedure and the level of care.

Policy: Implantable Electrocardiographic Event Monitors (0547)

Effective: dates of service beginning October 25, 2019

Update: Cigna will implement a new medical coverage policy, Implantable Electrocardiographic Event Monitors (0547), to review the use of these devices for medical necessity.

  • This update affects claims billed with CPT code 33285 and Healthcare Common Procedure Coding System (HCPCS) codes C1764 and E0616.

Medical Coverage Policies

Policy: Angioplasty (Extracranial, Intracranial) and Endoluminal Flow Diverting Devices (0545) New

Effective: October 15, 2019

Update: Originally provided advance notification on July 15, 2019

  • Addresses medical necessity of certain angioplasty procedures.
  • Precertification required.

Policy: Head and Neck Ultrasound (0549) New

Effective: October 21, 2019

Update: Originally provided advance notification on July 18, 2019

  • Addresses medical necessity of ultrasound of soft tissues of the head and neck.

Policy: Implantable Electrocardiographic Event Monitors (0547) New

Effective: October 25, 2019

Update: Originally provided advance notification on July 18, 2019

  • Precertification required.

Policy: Scrotal Ultrasound (0548) New

Effective: October 21, 2019

Update: Originally provided advance notification on July 18, 2019

  • Addresses medical necessity of ultrasound of the scrotum.

Policy: Corneal Remodeling for Refractive Errors (0141) Modified

Effective: October 15, 2019

Update: Minor changes in coverage criteria/policy:

  • Updated title from Corneal Remodeling to current title.
  • Removed qualifying verbiage about progressive deterioration in vision from existing policy statement.

Policy: Cryounits/Cooling Devices (0314) Modified

Effective: October 15, 2019

Update: Important change in coverage criteria:

  • Added new not medically necessary (NMN) policy statement for scalp cooling.

Policy: Genetic Testing for Hereditary and Multifactorial Conditions (0052) Modified

Effective: October 15, 2019

Update: Important change in coverage criteria:

  • Changed policy statement rationale from experimental, investigational or unproven (EIU) to NMN for certain indications.

Policy: Intervertebral Disc (IVD) Prosthesis (0104) Modified

Effective: October 15, 2019

Update: Minor change in criteria/policy:

  • Updated existing EIU policy statement with criteria about treatment at adjacent or other level.

Policy: Kidney Transplantation, Pancreas-Kidney Transplantation, and Pancreas Transplantation Alone (0146) Modified

October 15, 2019

Update: Important changes in coverage criteria:

  • Removed some criteria requirements in existing policy statement for simultaneous pancreas-kidney (SPK) transplantation.
  • Revised policy statement criteria for pancreas transplantation alone (PTA) and pancreas-after-kidney transplantation (PAK).

Policy: Nonpharmacological Treatments for Atrial Fibrillation (0469) Modified

Effective: October 15, 2019

Update: Important changes in coverage criteria:

  • Updated title from Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins for the Treatment of Atrial Fibrillation to current title.
  • Added policy statement for coverage of transcatheter ablation of the pulmonary veins.
  • Added percutaneous transcatheter closure of the left atrial appendage (LAA) information from Omnibus Codes – (0504), maintaining EIU position.
  • Added surgical occlusion of the LAA to existing EIU policy statement.
  • Added policy statement for coverage of the surgical Maze or modified Maze procedure.
  • Added policy statement that minimally invasive off-pump Maze procedure, including a hybrid or convergent ablation procedure considered EIU.

Policy: Nucleic Acid Pathogen Testing (0530)

Effective: effective November 1, 2019

Update: Originally provided advance notification of important changes in coverage criteria on August 1, 2019

  • Removed coverage for several symptom-related diagnosis codes related to Gardnerella.
    • Will continue to cover for high-risk behaviors.
  • Clarified the asymptomatic bullet of the first policy statement.

Policy: Omnibus Codes (0504) Modified

Effective: October 15, 2019

Update: Minor changes in coverage criteria/policy:

  • Removed section for percutaneous transcatheter closure of the LAA:
  • CPT code 33340.
  • Added information to Nonpharmacological Treatments for Atrial Fibrillation – (0469).

Policy: Sacral Nerve Stimulation for Urinary Voiding Dysfunction and Fecal Incontinence (0404) Modified

Effective: October 15, 2019

Update: Important changes in coverage criteria:

  • Updated language in existing policy statement about screening trial.
  • Removed some criteria requirements from the existing policy statement.
  • Added new policy statement for coverage of maintenance therapy.

Policy: Tumor Profiling, Gene Expression Assays, and Molecular Diagnostic Testing for Hematology/Oncology Indications (0520) Modified

Effective: October 15, 2019

Update: Important changes in coverage criteria:

  • Changed “mutation” to “pathogenic” or “likely pathogenic” for clarity.
  • Revised criteria for gene expression classifier testing.
  • Added criteria for medical necessity of the Breast Cancer Index test and EndoPredict test.
  • Added statement to reflect that the Oncotype DX Breast DCIS Score is EIU.
  • Added medical necessity criteria for AR-V7 circulating tumor cell testing.
  • Amended policy statement to reflect somatic testing for selected solid neoplasms remains EIU unless required for management of tumor agnostic pharmacologic therapy.

For more information or to view Cigna’s existing policies, including an outline of monthly coverage policy changes and a full listing of medical coverage policies, visit the Cigna for Health Care Professionals website.

CPT® is a registered trademark of the American Medical Association.
Source(s): Cigna Network News October 2019;

 

 

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