Drug and Biologic Coverage Policy: Etranacogene dezaparvovec-drlb

https://static.cigna.com/assets/chcp/pdf/coveragePolicies/pharmacy/ip_0535_coverageposition_etranacogene_dezaparvovec_drlb.pdf 

CIGNA to Start Denying Modifier 25 Claims in May
Effective May 25, 2023, Cigna will begin denying E/M claims with modifier 25 when billed with a minor procedure, unless you submit office notes to support the significant and separately identifiable E/M service you’re submitting.

Cigna originally tried to roll out this policy a year ago, but after significant pushback, the payer said it would reevaluate that policy rather than implementing it in 2022. But clearly, that reevaluation is complete, with Cigna issuing its updated policy last month.

In black and white: The policy states, “Cigna requires the submission of office notes with claims submitted with E/M CPT codes 99212, 99213, 99214 and 99215, and modifier 25 when billed with a minor procedure. The E/M line will be denied if Cigna does not receive adequate documentation to support that a significant and separately identifiable service was performed. The documentation should be submitted with a cover sheet indicating the office notes supports the use of modifier 25 appended to the E/M code.”

Keep in mind that although the policy starts May 25 in most states, there may be different dates in other locations. For instance, the policy doesn’t start until June 11 in Texas, so check with your Cigna representatives to see when it starts in your state.

NOTHING WAS SPECIFICALLY STATED ABOUT DRUG ADMIN.

Updated Informational Documents
Originally provided advance notification on December 15, 2023, of important changes, effective March 15, 2023:

• Clinical Information to Establish Medical Necessity 
• Expanded coverage in six guidelines:
• Abdomen 
• Breast 
• Chest 
• Head 
• Pediatric Abdomen 
• Pediatric Cardiac 
• Expanded and/or limited coverage in eight guidelines:
• Cardiac
• Neck
• Oncology
• Pelvis
• Peripheral Vascular Disease
• Pediatric Head
• Pediatric Musculoskeletal
• Pediatric Oncology
• No changes to remaining ten guidelines:
• Musculoskeletal
• Peripheral Nerve Disorders
• Preface
• Spine
• Pediatric Chest
• Pediatric Neck
• Pediatric Pelvis
• Pediatric Peripheral Nerve Disorders
• Pediatric Peripheral Vascular Disease
• Pediatric Spine

https://www.evicore.com/cignamedicare