Cigna Implementation Resources

Program

Description

Durable Medical Equipment

EviCore coordinates durable medical equipment services for select Cigna customers. EviCore also manages the network for these services.

Gastroenterology

January 1, 2022 (most Cigna commercial [non-Medicare] customers) EviCore manages precertification for the procedures listed below for Cigna customers who have an outpatient precertification requirement.

• Esophagoscopy/Esophagogastroduodenoscopy
• Most capsule endoscopies

Precertification helps ensure these procedures are medically necessary according to evidence-based guidelines.

Home health (includes home infusion therapy)

EviCore coordinates home health and home infusion therapy (nonspecialty) services for select Cigna customers. EviCore also manages the network for these services.

Musculoskeletal     EviCore manages precertification and clinical appeals for Cigna customers in most markets for outpatient and inpatient musculoskeletal services (e.g., interventional pain and joint surgery procedures).

Level of care

Precertification requirements for certain procedures, including total knee replacement and total hip replacement, include a medical necessity review for the level of care.

Site of care

Precertification requirements for some procedures may include a medical necessity review of the site of care. This only applies in certain markets for Cigna commercial customers who have fully insured plans.

Oncology

Cigna and EviCore offer a comprehensive oncology program that promotes affordability, predictability, and simplicity.

Clinical consult service

• The clinical consult service provides support to community oncologists to enhance patient outcomes.
• Community oncologists have the opportunity to collaborate with an oncologist who specializes in the patient’s cancer type and practices at a National Cancer Institute-designated or a National Comprehensive Cancer Network-affiliated cancer center.

The service is available for patients with select cancer diagnoses who have Cigna coverage and may benefit from a review of their diagnosis and treatment plan.                                                                                               

Clinical trial management

• EviCore manages outpatient medical oncology clinical trial prior authorization requests for Cigna commercial customers.
• Cigna performs utilization management for all inpatient oncology cases.

EviCore searches the National Cancer Institute’s oncology clinical trial database to help match customers to clinical trials.                                        

Integrated Oncology Management Program

EviCore manages precertification for medical and pharmacy oncology drugs.                                                                                                                       

Value-based pathways program

• The value-based pathways program promotes the use of clinically appropriate, safe, and cost-effective therapies to improve patient outcomes.

The program improves quality and value in cancer care by providing treating oncologists with evidence-based data to assist them in selecting chemotherapy regimens that represent the highest value for their patients with Cigna coverage.

Radiation oncology

EviCore manages precertification for select outpatient radiation therapy services.

Radiology

EviCore manages precertification for high-tech radiology and diagnostic cardiology services.

Precertification requirements for computed tomography scans and magnetic resonance imaging include a medical necessity review of the site of care for customers who have fully insured plans, Self-Insured Plans and Individual & Family Plans as well as those in the Cigna employees benefit plan.

Sleep

EviCore coordinates and manages precertification for sleep services for select Cigna customers.