Coverage Policies

 

Supporting Websites

In certain markets, Cigna may use vendor guidelines to support utilization management activities of specific services, including chiropractic care, physical and occupational therapy and advanced radiology services. In these situations, vendor guidelines may be used to support medical necessity and other coverage determinations.

• eviCore Guidelines
• ASH - American Specialty Health (Therapy & Related Services)
• Cigna State Specific Guideline (AL, AR, CO, CT, MA, WA)
• MCG Guidelines
• Medicare Drug List Formulary

 

Cigna Healthcare Medicare Advantage Coverage Policy Development and Application

Medicare Advantage (MA) coverage policies list the criteria our clinicians use to decide when medical services are considered “reasonable and necessary” (also called “medically necessary”).

Centers for Medicare & Medicaid Services (CMS) require MA plans to provide the same medical benefits as original Medicare. MA plans must follow National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). They must also follow general coverage and benefit conditions in original Medicare laws. That includes using the same coverage criteria to decide if an item or service is covered by original Medicare.

There are times when a Medicare statute, regulation, NCD or LCD does not fully establish coverage criteria. When that happens, CMS allows MA plans like Cigna to create and use our own internal coverage criteria policies. We must base those policies on current evidence in widely used treatment guidelines or clinical literature. And they must be publicly accessible.
(42 CFR 422.101(6) (i)):
(i) Coverage criteria not fully established. Coverage criteria are not fully established when:

1. Additional, unspecified criteria are needed to interpret or supplement general provisions in order to determine medical necessity consistently. The MA organization must demonstrate that the additional criteria provide clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services;
2. NCDs or LCDs include flexibility that explicitly allows for coverage in circumstances beyond the specific indications that are listed in an NCD or LCD; or
3. There is an absence of any applicable Medicare statutes, regulations, NCDs or LCDs setting forth coverage criteria.

We will only use an internal coverage policy for a customer’s specific condition when a Medicare policy, an NCD or LCD is not fully established. CMS policies are not fully established when any of the following apply :

• More criteria are needed to interpret or support general provisions in an NCD, LCD or other Medicare coverage policy; or
• There is flexibility allowed in an NCD or LCD; or
• There is no applicable NCD or LCD to decide medical necessity; or
• There is no applicable Local Coverage Article (used with an LCD) to decide medical necessity; or
• A Medicare policy does not address the customer’s specific condition for the request under review; or
• A Medicare policy does not include specific coverage criteria. A Medicare policy may have broad guidelines, but it may not have enough detail to decide if the request is medically necessary.

Additionally, we may use our own policies when a Medicare policy allows for more coverage than what is written in the Medicare policy. When our clinicians use internal clinical criteria, each customer’s unique clinical situation is considered with current CMS guidelines and our clinical policies, as applicable.

Each Cigna coverage policy lists clinical benefits. And they address any clinical harm and access to services. Each internal coverage policy is developed following:

• An objective process based on scientific evidence
• Generally accepted and current standards of medical practice
• Authoritative clinical practice guidelines

We use the following Medicare Advantage Medical Decision Hierarchy to decide medical necessity:

1. The Law (Title 18 of the Social Security Act)
2. The Regulations (Title 42 Code of the Federal Regulations (CFR))
3. National Coverage Determinations (NCDs)
4. Medicare Benefit Policy Manual (IOM 100-02)
5. Local Coverage Determinations (LCDs)
6. CMS Coverage guidelines in Interpretive Manuals (Internet Only Manual (IOM) Sub-manuals
• Pub 100-04 Medicare Claims Processing
• Pub 100-08 Medicare Program Integrity
• Pub 100-10 Quality Improvement Organization
• Pub 100-16 Medicare Managed Care Manual
7. Durable Medical Equipment Medicare Administrative Contractor (DMEMAC)
8. Program Safeguard Contractor (PSC) local coverage determinations
9. Cigna Healthcare Coverage Policies
• Cigna Healthcare Coverage Policy Unit
• eviCore co-branded
10. Vendor Partner Guidelines
11. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines
12. Part B Drug/Biologic Coverage Parity & Step Therapy Policies
13. Cigna Healthcare Standards and Guidelines/Medical Necessity Criteria for Behavioral Health
14. MCG Health Clinical Guidelines, most recent edition available
15. Supplemental Benefits and Limitations as outlined in the Member’s Evidence of Coverage
16. U.S. Food and Drug Administration (FDA) Approved Indications for Medications not outlined in specific LCDs
17. Other major payer policy and peer reviewed literature
18. Utilization Management Policies and Procedures (such as Network Adequacy, Continuity of Care and Transition of Care)
19. Additional Medical Director Resources (such as Hayes, Wolters Kluwer Clinical Drug Information Lexi-Drugs (Up to Date), Medical Inquiry Database)

We use the following Medical Necessity Decision Hierarchy for Part B to decide medical necessity:

1. The Law (Title 18 of the Social Security Act)
2. The Regulations (Title 42 Code of the Federal Regulations (CFR))
3. National Coverage Determinations (NCDs)
4. Medicare Benefit Policy Manual (IOM 100-02)
5. Local Coverage Determinations (LCDs)
6. Cigna Healthcare Coverage Policies
• Cigna Healthcare’s Coverage Policy Unit
• eviCore co-branded
7. MCG Health clinical guidelines, most recent edition available
8. Compendium:
• National Comprehensive Cancer Network (NCCN) Drugs and Biologics
• Truven Health Analytics Micromedex (DrugDEX)
• Wolters Kluwer Clinical Drug Information Lexi-Drugs (Up-to-date)
• American Hospital Formulary Service-Drug Information (AHFS-DI)
• Elsevier/Gold Standard Clinical Pharmacology

 

Supporting Behavioral Websites

Evernorth Behavioral Health uses a suite of existing evidence-based criteria to support your clinical judgment and decision-making processes. Most recently, for mental health care, Evernorth adopted externally developed Level of Care Utilization System (LOCUS) criteria for ages 18+, and Child and Adolescent level of Care/Service Intensity Utilization System (CALOCUS-CASII) criteria for ages 6 to 17, in compliance with California Senate Bill 855. These criteria will be used to conduct mental health level of care medical necessity reviews for all commercial health plans in California, unless federal or state law require the use of other specifically identified clinical criteria.

In addition to the medical coverage policies listed above, the following resources are used to make medical necessity determinations.

Updated August 2022

• MCG Behavioral Health Guidelines¹
  Evernorth uses this criteria, developed by MCG Health^®, for guidance in conducting medical necessity reviews of mental health levels of care for all health plan business, unless contractual requirements, federal or state law require use of other clinical criteria.
• The ASAM Criteria^®
  Evernorth uses this criteria, developed by the American Society of Addiction Medicine, for guidance in conducting medical necessity reviews of substance use disorder levels of care for all health plan business, unless contractual requirements, federal or state law require use of other clinical criteria.
• LOCUS and CALOCUS-CASII Criteria
  Evernorth uses the following criteria in California for guidance in conducting medical necessity reviews of mental health levels of care for all health plan business, unless contractual requirements, federal or state law require use of other clinical criteria.
  • LOCUS
  • CALOCUS-CASII
• Evernorth Authorization and Billing Resource
  For information on billing practices and authorization requirements, visit Resources > Behavioral Resources > Doing Business with Evernorth > Authorization and Billing Resource.
• State and federal regulations and licensing standards²
  
  • If applicable, refer to your state’s guidance to conduct mental health and substance use disorder level of care medical necessity reviews for commercial health plan business.

¹ On November 27, 2020, we terminated use of our Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders and transitioned to the MCG Behavioral Health Guidelines referenced above. Our former Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders are available for regulatory and reference purposes. This documentation will also be used throughout the duration of cases that are submitted to Cigna prior to November 27, 2020. These cases include:

• Prior authorization requests
• Continued care requests/concurrent reviews
• Appeals where the Cigna document is used in initial determinations

² Evernorth complies with state specific laws, as written.

 

Additional Information

• The terms of an individual's particular coverage plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard coverage plans upon which these coverage policies are based. If these Coverage Policies are inconsistent with the terms of the individual's specific coverage plan, then the terms of the individual's specific coverage plan always control.
• Coverage determinations in each specific instance require consideration of:
  • the terms of the applicable coverage plan document in effect on the date of service
  • any applicable laws/regulations
  • any relevant collateral source materials, including coverage policies
  • the specific facts of the particular situation
• Medical technology is continuously evolving; our coverage policies are subject to change without prior notice. Additional coverage policies may be developed as needed or may be withdrawn from use. Additionally, some coverage plans administered by Cigna HealthCare, such as certain self-funded employer plans or governmental plans, may not use Cigna HealthCare coverage policies. Doctors and individuals should contact their Cigna HealthCare representative for specific coverage information.
• Cigna also uses other tools developed by third parties to assist in interpreting health coverage plan provisions, including MCG™ Care Guidelines (Copyright © 2017 MCG Health, LLC), 20th Edition, 2017.
• Behavioral medical necessity criteria information can be provided, if requested.