Coverage Policies and Criteria

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Cigna HealthCare coverage policies are tools to assist in interpreting standard health coverage plan provisions. Please keep the following in mind when accessing these coverage policies.

Access Cigna's medical or pharmacy coverage policies:

Medical coverage policy index
Pharmacy coverage policy index

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• The terms of an individual's particular coverage plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard coverage plans upon which these coverage policies are based. If these coverage policies are inconsistent with the terms of the individual's specific coverage plan, then the terms of the individual's specific coverage plan always control.
  
• Coverage determinations in each specific instance require consideration of:
  • the terms of the applicable coverage plan document in effect on the date of service
  • any applicable laws/regulations
  • any relevant collateral source materials, including coverage policies
  • the specific facts of the particular situation
• Medical technology is continuously evolving; our coverage policies are subject to change without prior notice. Additional coverage policies may be developed as needed or may be withdrawn from use. Additionally, some coverage plans administered by Cigna HealthCare, such as certain self-funded employer plans or governmental plans, may not use Cigna HealthCare coverage policies. Doctors and individuals should contact their Cigna HealthCare representative for specific coverage information.
• Cigna also uses other tools developed by third parties to assist in interpreting health coverage plan provisions, including Milliman Care Guidelines©, a division of Milliman, Inc., 15th Edition, 2010.

In certain markets, Cigna delegates utilization management of specific services, including chiropractic care, physical and occupational therapy and advanced radiology services. In these situations, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

Refer to the following vendor websites for additional information:

American Specialty Health
MedSolutions
OrthoNet