CurrentCignaPolicy A018

Application of Cigna Healthcare Coverage Policy Criteria for Medicare Advantage Determinations

Governs when criteria from Cigna Healthcare Coverage Policies may be applied to determine medical necessity for Cigna Medicare Advantage enrollees when Medicare statutes, NCDs, or LCDs do not fully establish coverage criteria; affects adjudicators and medical reviewers handling Medicare Advantage claims.

Policy Summary

PayerCigna

PolicyApplication of Cigna Healthcare Coverage Policy Criteria for Medicare Advantage Determinations

Policy CodePolicy A018

Change TypeNo material changes

Effective Date08/08/2025

Next Review Date08/08/2026

Key ActionApply Cigna Healthcare Coverage Policy criteria for Medicare Advantage medical necessity determinations when Medicare statute, regulation, NCD or LCD does not fully establish coverage criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A018Coverage Policy Number

08/08/2025Effective Date

08/08/2026Next Review Date

7 codesExample not medically necessary codes

SSA / 42 USC 1395yLegal references cited

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Application of Coverage Policy Criteria

Application of coverage policy criteria for Medicare Advantage

Use these criteria when Medicare statute, regulation, NCD or LCD does not fully establish coverage criteria.

Application of coverage policy criteria: When Medicare statute, regulation, NCD or LCD does not fully establish coverage criteria, Cigna Healthcare Coverage Policy criteria (including items described as 'Not Covered or Reimbursable' in commercial business) may be applied to determine whether services for Medicare Advantage enrollees are reasonable and necessary.

Hierarchy of consideration: Coverage determinations must consider in order: the applicable benefit plan document; applicable laws and regulations; relevant collateral materials including Administrative Policies; and the specific facts of the case.

Nature of Administrative Policies: Administrative Policies are not treatment guidelines; they provide administrative guidance and are not recommendations for clinical care.

Basis of coverage policy criteria: Criteria in Cigna Healthcare Coverage Policies are developed through an objective process based on scientific evidence, generally accepted standards of medical practice, and authoritative clinical practice guidelines, and therefore are appropriate for use in Medicare Advantage determinations when Medicare criteria are not fully specified.

Example Codes — Not Medically Necessary

Examples listed as Not Medically NecessarymixedNot Covered

64624	Destruction by neurolytic agent, genicular nerve branches including imaging guidance
81418	Drug metabolism genomic sequence analysis panel (≥6 genes including CYP2C19, CYP2D6, duplication/deletion)
81443	Genomic sequence analysis panel for severe inherited conditions (≥15 genes)
81490	Autoimmune (rheumatoid arthritis) 12-biomarker prognostic algorithm
81525	Oncology (colon) 12-gene mRNA expression profiling recurrence score
81540	Oncology tumor of unknown origin 92-gene mRNA profiling
81554	Pulmonary disease (IPF) 190-gene mRNA analysis

When to Apply Coverage Policy Criteria

Prior Authorization

When to apply coverage policy criteria

Apply Cigna Healthcare Coverage Policy criteria for Medicare Advantage medical necessity determinations when Medicare statute, regulation, National Coverage Determination (NCD) or Local Coverage Determination (LCD) does not fully establish coverage criteria.

Administrative Terms and Policy Definitions

Administrative Policies

DefinitionAdministrative Policies provide further information about the administration of standard Cigna benefit plans and relate exclusively to administration of health benefit plans.

Hierarchy for coverage determinationsCoverage determinations must consider: 1) the applicable benefit plan document; 2) applicable laws/regulations; 3) relevant collateral materials including Administrative Policies; and 4) the specific facts of the case.

Not treatment guidanceAdministrative Policies are not recommendations for treatment and must never be used as treatment guidelines.

Conflict ruleIf there is a conflict, a customer's benefit plan document supersedes the Administrative Policy.

Cigna Healthcare terminology

Term