Cigna Healthcare Medicare Advantage Coverage Policy Development and Application - (A018)

Cigna’s A018 policy allows Cigna Healthcare Coverage Policy criteria to be used to determine Medicare Advantage coverage when Medicare statute/regulation, an NCD, or an LCD do not fully establish coverage criteria, and specifically lists CPT codes 64624, 81418, 81443, 81490, 81525, 81540, and 81554 as Not Medically Necessary (excluded) under this Administrative Policy. Key requirements: the applicable benefit plan document and applicable laws/regulations supersede Administrative Policies, and medical necessity determinations must be documented to align with plan terms, laws/regulations, relevant collateral materials (including Administrative Policies), and the specific facts of the case.

"When a Medicare statute, regulation, National Coverage Determination (NCD) or Local Coverage Determination (LCD) does not fully establish coverage criteria, Cigna Healthcare Coverage Policy criteri..."