Cigna April 2026: Default Noncoverage of CPT Category III (T) Codes

Effective April 15, 2026, Cigna clarifies that CPT Category III (T) codes are treated as temporary data‑collection codes and are generally considered experimental, investigational, or unproven unless a separate Cigna Coverage Policy explicitly provides coverage. Providers should default to a noncoverage presumption for services billed with Category III codes unless those codes are specifically addressed in the Related Coverage Resources or another substantive coverage policy. The guideline reinforces that Category III codes do not create standalone coverage and that coverage determinations may vary by market or delegated vendor guidelines. Consult the listed Related Coverage Resources and applicable market/delegated guidelines for any Category III codes that may meet coverage criteria.

Cigna Update: Enumerated Vitamin D Testing Indications, Limits & Exclusions

Effective 6/15/2026, Cigna’s Vitamin D Testing policy (0526) defines explicit, enumerated medical-necessity indications for total 25(OH)D (CPT 82306/0038U) and for active 1,25(OH)2D (CPT 82652), and sets repeat-testing limits. Total 25(OH)D testing is authorized only for listed conditions (e.g., rickets/osteomalacia, CKD, malabsorption, hyperparathyroidism, granulomatous disease, certain medications, extremes of age, prior deficiency, toxicity, specified genetic disorders), with repeat testing allowed only every 3 months when criteria are met. Active 1,25(OH)2D testing is limited to separate, specific indications (e.g., CKD, phosphate-wasting disorders, oncogenic osteomalacia, granulomatous or inflammatory diseases), and combined billing of both assays is expressly not covered. The policy reiterates that vitamin D testing for general population screening or unlisted indications is not covered; coverage decisions remain subject to plan language and applicable law.

Cigna: Prior Authorization Required for All Infliximab Products — Criteria, Duration, Specialist Prescriber

Cigna now requires prior authorization for benefit coverage of all infliximab products and will approve use only when the patient meets the policy’s specific Criteria and Dosing for the listed indications; requests for doses outside documented regimens will be reviewed case-by-case by a clinician. Approvals include defined durations (1 month = 30 days) and may be extended if the patient continues to meet criteria. Initial prescribing must be by or in consultation with a physician who specializes in the treated condition due to needed evaluation and monitoring. Coverage of non-preferred infliximab products is subject to a separate preferred-product management policy, and benefit plan documents or specific exclusions take precedence over this Coverage Policy.

Cigna 6/15/2026: Consolidated OSA Surgical, DISE & Hypoglossal Device Criteria

Effective 6/15/2026 Cigna consolidated and clarified surgical and device coverage criteria for obstructive sleep apnea (OSA), tying medical necessity to objective thresholds, prior PAP therapy status, and age/BMI/AHI/device-specific limits. DISE is medically necessary only in defined scenarios (adult PAP failure/intolerance or post‑op persistent OSA; adolescents with Down syndrome for implant candidacy; pediatric DISE when paired with airway surgery or post‑op evaluation). UPPP, multilevel/stepwise procedures, and MMA require documented multilevel retropalatal or multilevel collapse and prior PAP failure/intolerance or documented unwillingness, with standalone uvulectomy for OSA excluded. FDA‑approved hypoglossal nerve stimulation devices have device‑specific age, AHI, BMI, and DISE criteria, and all surgical/device coverage remains subject to the member’s specific benefit plan and correct coding for the service date.

Noncoverage: Home Ultraviolet Phototherapy (PUVA/UV) — Blue CHiP

Blue CHiP (Medicare and commercial) restates that home ultraviolet phototherapy (including PUVA and other home UV modalities) for dermatologic conditions is not covered, characterizing home use as a convenience rather than medically necessary. The policy notes FDA 510(k) clearance for a handheld UVB device but finds overall evidence insufficient to demonstrate home therapy is as safe or effective as office-based phototherapy. Key clinical concerns include lack of periodic dermatologist skin examinations, potential to miss early skin cancer, and limited comparative studies validating home PUVA or other home UV treatments. A single open-label trial showing comparable efficacy for home oral PUVA in hand eczema is acknowledged but deemed insufficient to change the noncoverage determination.

Cigna 4/15/2026: Clarified Medical Necessity for Breast Implant Removal/Replacement

Effective 4/15/2026, Cigna clarified medical necessity criteria for removal and replacement of silicone and saline breast implants, emphasizing plan-specific coverage and that the member’s benefit document controls. Removal is considered medically necessary for implant rupture confirmed on imaging (silicone), infection not responsive to medical therapy, implant exposure, Baker Grade IV capsular contracture, tissue necrosis, confirmed BIA‑ALCL or BIA‑SCC, interference with breast cancer diagnosis or treatment, and current use of Allergan BIOCELL textured devices. Replacement is covered only when meeting reconstructive criteria (post‑mastectomy/lumpectomy reconstruction or symmetry of the contralateral breast) with referenced CPTs; many procedures are excluded as cosmetic or not medically necessary, including removal of intact silicone implants for suspected systemic illness and routine removal of ruptured saline implants absent other indications. Providers should verify member plan terms and applicable state/federal mandates before proceeding.

Cigna Ofev Prior Auth & Documentation Requirements — Mar 15, 2026

Cigna updated prior authorization and documentation requirements for Ofev (nintedanib) under IP0312, reaffirming that PA is required and approvals are typically time‑limited to one year. Coverage pathways for IPF, PPF, and SSc‑ILD are specified with separate initial and continuation criteria; prescribers must be specialists and baseline/diagnostic measures (e.g., FVC ≥40% predicted, HRCT or biopsy findings) are explicitly required and marked as [documentation required]. Continuation approvals require documented clinical benefit over the prior year or comparison to baseline if treated less than a year. Concomitant use of Ofev with pirfenidone (Esbriet) and any non‑listed indications are deemed not medically necessary.

UHC Mar 2026 Bulletin: Policy Action Summary & Coverage Clarification

UnitedHealthcare’s March 2026 Medical Policy Update Bulletin lists policies that were newly adopted, revised, updated, replaced, or retired and clarifies that listing a service reflects a policy action but does not by itself indicate coverage. Coverage decisions remain governed by the member’s benefit plan and applicable federal/state law; UMR serves as a TPA for self‑funded plans and full policy details are available at UHCprovider.com/policies. The bulletin defines the action categories (New, Updated, Revised, Replaced, Retired) to standardize interpretation of changes and notes UnitedHealthcare may review clinical evidence before making coverage determinations. Providers may not bill members for noncovered services unless the member provides written consent acknowledging potential direct billing.

UnitedHealthcare: Dental Implant & Orthodontic Criteria Revised — Apr 1, 2026

UnitedHealthcare revised clinical coverage criteria for three dental policies—Dental Implant Placement and Treatment of Peri‑Implant Defects/Disease, Dental Implant Supported Prostheses, and Medically Necessary Orthodontic Treatment—effective April 1, 2026. The bulletin clarifies that “Revised” denotes changes to clinical coverage criteria and explains other status tags (New, Updated, Replaced, Retired). Inclusion in the bulletin does not guarantee member coverage; determinations remain subject to the member’s specific benefit plan and applicable federal or state law. Providers should consult the full dental clinical policy library on UHCprovider.com for complete criteria and follow plan documents before seeking payment or obtaining member consent for noncovered services.

Hydrogel Spacer Coverage Clarified — Photon EBRT Only (Apr 2026)

Effective 04/04/2026 Blue Cross Blue Shield of Louisiana restates coverage for implanted hydrogel spacers used with definitive photon-based external beam radiation for prostate cancer, specifying eligible photon modalities as 3D conformal, IMRT, and SBRT. Use of hydrogel spacers with prostate brachytherapy, proton beam therapy (PBT), or any indications beyond the listed photon modalities is deemed not medically necessary. Coverage remains subject to the member’s contract/certificate and fulfillment of the policy’s medical necessity criteria; the policy is based on peer-reviewed literature, specialty guidance, and physician input. Contractual language and applicable federal/state law take precedence over the policy.