Effective 8/1/2020 Cigna is requiring all Covid-19 testing to be deemed as medically necessary. This includes:
- Symptomatic individual, suspected of having COVID-19 as informed by ANY of the following
- Shortness of breath or difficulty breathing
- Repeated shaking with chills
- Sore throat
- New loss of taste or smell
- Congestion or runny nose
- Persistent pain or pressure in the chest
- Body aches or muscle pain
- New confusion
- Inability to wake or stay awake
- Bluish lips or face
- Suspected multisymptom inflammatory syndrome in children (MIS-C)
- Asymptomatic individual with ANY of the following:
- Known or suspected to have been exposed to an individual with a laboratory-confirmed case of COVID-19
- Being admitted to the hospital in areas with a high prevalence of COVID-19 in the community (i.e., prevalence ≥10%)
- Immunocompromise, being admitted to the hospital before immunosuppressive procedures (i.e., cytotoxic chemotherapy, organ or stem cell transplantation, long-acting biologic therapy, cellular immunotherapy, high-dose corticosteroids) prior to surgical procedure, when the ordering healthcare provider has determined that results of testing will impact medical care prior to aerosol generating procedure (i.e., bronchoscopy, open suctioning of airways, sputum induction, cardiopulmonary resuscitation, endotracheal intubation and extubation, non-invasive ventilation (e.g., BiPAP, CPAP), bronchoscopy, manual ventilation).
- An antibody (serology) test is considered medically necessary in a symptomatic individual age ≤ 21 years
to aid in the diagnosis of suspected multisystem inflammatory syndrome in children (MIS-C) when the
following criteria are met:
- Recommended by a health care provider
- FDA approved or cleared or emergency use authorized (EUA)
- Performed by a CLIA-accredited high or medium-complexity laboratory (per test Instructions for Use)
- Molecular (nucleic acid) or antigen in vitro diagnostic test as noted above is non-diagnostic for COVID-19.
- Not Medically Necessary:
- Molecular, antigen or antibody (serology) testing in a symptomatic or asymptomatic individual with known or suspected exposure to COVID-19 infection is considered not medically necessary for any indication other than the ones listed above.
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Medical Coverage Policy: 0557
A high-throughput molecular or antigen in vitro diagnostic test for the diagnosis of COVID-19 infection will not be covered unless billed by a CLIA-accredited high-complexity laboratory.
Under most benefit plans, in vitro testing is not covered for population or public health screening including but not limited to, the following indications:
- Determine prevalence of COVID-19 infection in the community or congregate setting
- Participation in sports
- Admission to residential institution
- Routine and/or executive physicals
- Molecular in vitro diagnostic testing using pooled samples is not covered as this is considered screening.
- Over-the-Counter (OTC) tests for the diagnosis of COVID-19 infection are not covered.
- Please contact Cigna directly if you have questions about what is not covered.