Coverage Policies

When a surgery involves more than one surgical procedure covered under a customer's plan, reimbursement policies apply.

Reimbursement Policy

Multiple Procedures

Procedures performed during the same operative session by the same provider (known as "multiple procedures") are reimbursed following these guidelines:

• 100% allowable for major procedure, or first surgical procedure
• 50% allowable for all other procedures

Bilateral Procedures

Procedures performed on both sides of the same anatomical site and are a bilateral eligible procedure, are reimbursed following these guidelines:

• 150% of the fee schedule amount for a single procedure

Exclusions

• This policy may not apply to facility charges.
• This policy does not apply to procedures deemed to be Modifier 51-exempt. A Modifier-51 is used to indicate the subsequent surgeries/procedure(s) that are performed during a single session.

Quick Tips

• Assistant surgeon fees are also subject to multiple procedure policy. Participating providers cannot balance bill customers for charges in excess of Cigna HealthcareSM allowable amounts.
• In some cases, the office visit is not separately reimbursable from the surgical code; the office visit copay does not apply.
• Always check our Clean Claim Requirements before submitting your claim for payment.

Medical Necessity for Physicians

"Medically Necessary" or "Medical Necessity" means health care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed, medical literature generally recognized by the relevant medical community
2. Physician Specialty Society recommendations
3. The views of physicians practicing in the relevant clinical area
4. Any other relevant factors

Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Medical Necessity for Other Health Care Providers

Except where state law or regulation requires a different definition, "Medically Necessary" or "Medical Necessity" refers to health care services that a health care provider, exercising prudent clinical judgment, would provide to a patient. The service must be:

1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
2. In accordance with the generally accepted standards of medical practice
3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease

For these purposes, "generally accepted standards of medical practice" means:

1. Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community
2. Physician and Health Care Provider Specialty Society recommendations
3. The views of physicians and health care providers practicing in relevant clinical areas
4. Any other relevant factors

Preventive care may be Medically Necessary, but coverage for Medically Necessary preventive care is governed by terms of the applicable Plan Documents.

Medicare Definition of Medical Necessity

Learn more about the Medicare Advantage medically necessary requirements.

Medical Necessity Criteria for Treatment of Mental Health and Substance Use Disorders

Cigna Healthcare believes that all treatment decisions that are made in alignment with the Medical Necessity Criteria must be first and foremost clinically based. Care must be patient-centered and take into account the individuals’ needs, clinical and environmental factors, and personal values.

Learn more about our Behavioral Health Guidelines. 

Understand when consumable medical supplies are covered, and what is considered a consumable medical supply.

What is a consumable medical supply?

Consumable medical supplies (also known as medical consumables) are non-durable medical supplies that:

• Are usually disposable in nature
• Cannot withstand repeated use by more than one individual
• Are primarily and customarily used to serve a medical purpose
• Generally are not useful to a person in the absence of illness or injury
• May be ordered and/or prescribed by a physician.

Plan Exclusions: Most plans contain exclusions for consumable medical supplies. Although plan language varies considerably, a typical exclusion defines consumable medical supplies as including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips.

When does Cigna Healthcare allow coverage for consumable medical supplies?

Consumable medical supplies are covered under our coverage policies in conjunction with:

• Inpatient hospital services
• Outpatient hospital facility services
• Home health services
• Diabetic services
• Breast reconstruction and breast prostheses
• Wigs

Additional Managed Care Guidelines:

• Consumable medical supplies can be allowed under the lead referral/precertification for the associated services.
• Ostomy supplies are covered.
• If consumable medical supplies are not provided in conjunction with authorized or referred services, and are not covered under the plan for benefits, they will not be reimbursed by Cigna Healthcare℠.

Note: State or federal legislation and/or plan-specific language supersede the administrative coverage policies of Cigna Healthcare.

How do health care providers get reimbursed?

Reimbursement guidelines vary, dependent on the type of medical supply, however all consumable medical supplies should be billed using the applicable Healthcare Common Procedure Coding System (HCPCS) codes.

• Casting & Splint Supplies (Q4001-Q4051) are payable in addition to other services billed on the claim.
• Consumable medical supplies provided in conjunction with Durable Medical Equipment (DME) are covered if the supplies are necessary for the function of the equipment and the equipment is covered under the plan.
• Diabetic Supplies
  • Claims for insulin needles and syringes (A4206, A4207, A4208, A4209, A4215) will be paid under the customer's benefit plan, either medical or pharmacy.
  • Claims for lancets (A4258 and A4259) will be denied as consumable supplies, unless covered under state mandate or pharmacy rider.
  • Claims for glucose test strips (A4772, A4253) will be denied as consumable supplies, unless covered under state mandate or pharmacy rider.
  • Claims for glucometer devices (E0607, E0609) will be paid under the DME benefit.
• Surgical Trays are considered reimbursable for select procedures. For more information, please log in to the CignaforHCP portal.
• Oxygen and Oxygen Delivery Systems/Supplies are not considered consumable supplies or DME. They are only reimbursed if covered under a customer's medical benefit.
• Breast Reconstruction and Prostheses are covered under the EPA benefit. Mastectomy bras are covered following a mastectomy under a customer's medical benefit.
• Wigs are subject to the customer’s medical benefit.