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Cigna July 2017 Medical Policy Updates

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Cigna July 2017 Medical Policy Updates

 

Cigna July 2017 Medical Policy Updates »

The following Medical Policies have been updated;

July 2017

MEDICAL COVERAGE POLICY
Unless otherwise noted, the following medical coverage policies were modified effective July 15, 2017:
Genetic Testing for Hereditary Cancer Susceptibility Syndromes – (0518) Modified
  • Important change in coverage criteria:
    • Added coverage for testing for hereditary paraganglioma-pheochromocytoma (PGL/PCC) syndrome.
Tumor Profiling, Gene Expression Assays, and Molecular Diagnostic Testing for Hematology/Oncology Indications – (0520) Modified
  • Important change in coverage criteria:
    • Updated criteria for diagnostic testing for primary myelofibrosis.
Policies Status Details
PHARMACY (DRUGS & BIOLOGICS) POLICIES
Unless otherwise noted, the following pharmacy (drugs & biologics) coverage policies were modified effective July 15, 2017:
Canakinumab – (1110) Modified
  • Important changes in coverage criteria:
    • Added criteria (consistent with interim approach) for:
      • Familial Mediterranean fever (FMF)
      • Hyperimmunoglobulin D (Hyper-IgD) syndrome (HIDS)/mevalonate kinase deficiency (MKD)
      • Tumor necrosis factor (TNF) receptor associated periodic syndrome (TRAPS)
Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Standard Prescription Drug List and Performance Prescription Drug List – (1601) Modified
  • Important changes in coverage criteria, effective July 1, 2017:
    • Updated criteria (consistent with interim approach) for:
      • Jardiance
      • Synjardy/Synjardy XR
      • Glyxambi
    • Added criteria for:
      • metformin ER tablets (generic for Glumetza)
      • Gelnique (consistent with interim approach)
      • Adlyxin
      • Basaglar
    • Updated criteria for Belbuca:
      • Reflects generic availability of Butrans® (buprenorphine transdermal patch)
    • Updated criteria for Aplenzin, Wellbutrin XL, Cymbalta, Lexapro, and Pexeva® to reflect the availability of generic Pristiq
      • Removed requirement of brand Pristiq and added the generic, desvenlafaxine succinate ER, to the list of alternatives.
Drugs / Biologics Not Covered Unless Approved Under Medical Necessity Review – Employer Group Plans: Value Prescription Drug List and Advantage Prescription Drug List – (1602) Modified
  • Important changes in coverage criteria, effective July 1, 2017:
    • Updated criteria for Vytorin (ezetimibe/simvastatin) to reflect generic availability.
    • Updated criteria (consistent with interim approach) for:
      • Jardiance
      • Synjardy/Synjardy XR
      • Glyxambi
    • Removed criteria (consistent with interim approach) for:
      • Farxiga
      • Xigduo
    • Added criteria for:
      • metformin ER tablets (generic for Glumetza)
      • Gelnique (consistent with interim approach)
      • Adlyxin
      • Basaglar
      • Updated criteria for Belbuca:
        • Reflects generic availability of Butrans (buprenorphine transdermal patch)
      • Updated criteria for Aplenzin, Wellbutrin XL, Cymbalta, Lexapro, and Pexeva to reflect the availability of generic Pristiq
        • Removed requirement of brand Pristiq and added the generic, desvenlafaxine succinate ER, to the list of alternatives.
Eculizumab – (1103) Modified
  • Important change in coverage criteria:
    • Added criteria requiring meningococcal vaccine for paroxysmal nocturnal hemoglobinuria (PNH).
Hydroxyprogesterone caproate injection – (1108) Modified
  • Important change in coverage criteria:
    • Removed Delalutin criteria based on business decision to remove from medical precertification.
Octreotide – (5015) Modified
  • Important change in coverage criteria:
    • Reinstated criteria for oncology uses.
Oncology Medications – (1403) Modified
  • Important change in coverage criteria:
    • Added criteria to not allow concomitant administration of Xtandi with Zytiga.
    • Removed Octreotide:
Policies Status Details
CIGNA-EVICORE COBRANDED IMAGING GUIDELINES
Updated 20 (Adult and Pediatric for each) Cigna-eviCore Cobranded Imaging Guidelines, effective July 14, 2017:
  • Abdomen
  • Cardiac
  • Chest
  • Head
  • Musculoskeletal
  • Neck
  • Pelvis
  • Peripheral Nerve Disorders (PND)
  • Peripheral Vascular Disease (PVD)
  • Spine
Policies Status Details
ADMINISTRATIVE POLICIES
No updates for July 2017.
Policies Status Details
CAREALLIES MEDICAL NECESSITY GUIDELINES
Various Modified Nine policies have been posted to the CareAllies Medical Necessity Guidelines (CAMNG).

*Please log in to view these policies.

Policies Status Details
PRECERTIFICATION POLICIES*
No updates for July 2017.
Policies Status Details
REIMBURSEMENT POLICIES*
Updates have been made to the following:
R27 Related Services Supplies Drugs and Equipment New
R12 Facility Routine Services, Supplies and Equipment

R15 Respiratory Services and Supplies

 Modified
Policies Status Details
CLAIM EDITING POLICIES AND PROCEDURES*

 CLAIMSXTEN
No updates for July 2017
Policies Status Details
POLICIES WITH A REDUCTION IN COVERAGE
We are changing how we reimburse providers as follows:.
R27 Related Services, Supplies, Drugs, and Equipment

CP 0160 Electrical Stimulation Therapy and Devices

 Effective July 9, 2017, we will implement a new policy, Related Services, Supplies, Drugs, and Equipment (R27), and deny reimbursement for supplies associated with Electrical Stimulation Therapy and Devices (0160) if the claim for the device was previously denied.

The update will apply to claims processed on or after July 9, 2017, whether the supplies are billed with the device or separately.
R12 Facility Routine Services, Supplies and Equipment

R15 Respiratory Services and Supplies

 Effective July 24, 2017, and consistent with our reimbursement policies, we will not separately reimburse for point-of-care services performed by nursing and other ancillary staff at inpatient facilities. Point-of-care services are services provided at the patient bedside or near the site of patient care (for example, rapid diagnostic testing). These services are included in the reimbursement for inpatient room and board.

The update will apply to claims processed on or after July 24, 2017.

 

Policy Alerts monitors Commercial and Medicare medical policies for changes. While Payers typically update medical policies annually, there are many reasons why a Payer might review or update a policy. When reviews occur out of cycle, they may go unnoticed. Policy Alerts keeps you informed of upcoming and unexpected coverage changes affecting your product. Quickly understanding the changes Payers make can help you adjust reimbursement strategies impacting your business.

Policy Alerts continuously monitors Commercial and Medicare Payer coverage information to keep you up-to-date on Payer decisions in real-time. Whenever changes occur, email notifications containing a summary of those changes are delivered to your inbox. Clients can access detailed coverage reports and medical policies on the interactive Dashboard portal. Save time and keep focused on the important Payer medical policy reviews and coverage decisions affecting your product!

Policy Alerts takes a client-focused hands-on approach and works hard to provide our customers with helpful insights and actionable analytics over raw data. We understand what our clients need and we are dedicated to making sure we provide timely, accurate and always up-to-date reports that can be used to implement and support a successful reimbursement strategy.

Health economic and reimbursement information provided by Policy Alerts is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice.

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