Cohere Health’s Scope of Management, Cardiovascular, and Surgical Services: Prior Authorization List
Overview
Cohere Health, a patient journey optimization company, is designated the exclusive preauthorization and utilization management vendor for Humana’s cardiology, surgical services and endoscopy, and musculoskeletal services. Note: Cohere began managing musculoskeletal services in 2021.
Impacted Plans and Geographies
Impacted plans and geographies will include most Humana Medicare Advantage, some Commercial, and a subset of dual Medicare-Medicaid plans in all 50 states and the District of Columbia.
Clinical Scope
Practices must use Cohere when requesting preauthorization for any of the procedure codes or services listed in the table below.
For more information and to view the official and most up to date Humana Preauthorization List (PAL), please visit Humana’s provider website (www.humana.com/PAL). Please note, in addition to the procedure codes, other request criteria may impact submission requirements.
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All practices are encouraged to submit preauthorization requests electronically by registering* for a Cohere account. Only Cohere users can benefit from instant authorization decisions, if eligible.
* If your practice already has access to Cohere, please ask any existing Cohere administrative user(s) at your practice to create an account for you. |
1. For a list of musculoskeletal codes delegated to Cohere, please visit www.coherehealth.com/provider/resources.
2. Several exclusions apply. For instance, Cohere will not be used for members with Medicare HMO policies in FL, CA, and HI. These members will continue to get authorizations through their primary care provider. Please contact Humana for more information.
Use Cohere to obtain preauthorizations for the following procedure codes:
| Cardiology | |
| Service Category | Procedure Codes (HCPCS) |
| Ablation | 93650, 93654, 93653, 93656 |
| Cardiac Devices |
0266T, 0267T, 0268T, 0269T, 0270T, 0271T, 0272T, 0273T, 0408T, 0409T, 0410T, 0411T, 0413T, 0414T, 0415T, 0416T, 0417T, 0418T, 0571T, 0572T, 0573T, 0574T, 0580T, 0614T, 0823T, 0824T, 0825T, 0826T, 0915T, 0916T, 0917T, 0918T, 0919T, 0920T, 0921T, 0922T, 0923T, 0924T, 0925T, 0926T, 0927T, 0933T, 0934T, 33206, 33207, 33208, 33210, 33211, 33212, 33213, 33214, 33216, 33217, 33221, 33224, 33227, 33228, 33229, 33230, 33231, 33233, 33234, 33235, 33240, 33241, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 33274, 33275, 33285, 33286, 33289, 33340, 93228, 93229, C1605, C1721, C1722, C1777, C1779, C1785, C1786, C1824, C1825, C1882, C1895, C1896, C1898, C1899, C1900, C2619, C2620, C2621, C2624 |
| Cardiac Procedures/Surgeries |
0345T, 0716T, 0913T, 0914T, 33361, 33362, 33363, 33364, 33365, 33366, 33418, 33875, 33877, 33880, 33881, 33883, 33886, 34701, 34702, 34703, 34704, 34705, 34706, 34830, 34831, 34832, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 35301, 37215, 37216, 37217, 37218, 47133, 92920, 92928, 92924, 92933, 92937, 92943, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93580, 93593, 93594, 93595, 93596, 93597, C9600, C9602, C9604, C9607 |
| Cardiac Imaging |
36245, 36246, 36247, 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 93350, 93351, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93355, 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93624, 93631, 93640, 93641, 93642, 93644, 0577T, A9611, C8925, C8926, C8927, C8928, C8930, C8931, C8932, C8933, C8934, C8935, C8936 For repeat only: 93306, 93307, 93308, C8923, C8924, C8929 |
| Peripheral Intravascular Lithotripsy |
C9764, C9765, C9766, C9767, C9772, C9773, C9774, C9775, C1761, 92972 |
| Peripheral Revascularization |
37228, 37229, 37230, 37231, 37220, 37221, 37224, 37225, 37226, 37227, 37236, 37238, 0505T, 0234T, 0235T, 0236T, 0237T, 0238T |
| Other Durable Medical Equipment |
G0555 |
|
Ventricular Assist Devices (VADs) |
33995, 33990, 33991 |
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Surgical and Endoscopy Services |
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Service Category |
Procedure Codes (HCPCS) |
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Abdominoplasty |
15830, 15847 |
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Bladder slings |
57288 |
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Blepharoplasty |
15820, 15821, 15822, 15823, 67900, 67903, 67904, 67908, 67909, 67911, 67914, 67916, 67917, 67921, 67923, 67924, 67950 |
|
Breast Procedures (non-oncologic) |
11971, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19370, 19371, 19380, C1789, L8600 |
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Capsule Endoscopy |
91110, 91111, 91113, 0651T |
|
Colonoscopy (repeat only) |
45378, 45380 |
|
Cutaneous Vascular Lesion Removal |
17106, 17107, 17108 |
|
Decompression of peripheral nerve (i.e., carpal tunnel surgery) |
29848, 64721 |
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Diagnostic esophagogastroduodenoscopy (EGD) or esophagoscopy |
43191, 43193, 43197, 43198, 43200, 43202, 43235, 43239, 0652T, 0653T, 0654T |
|
Esophagogastroduodenoscopy (EGD) |
43235, 43237, 43238, 43239, 43242, 43252, 43253, 43259 |
|
Gastric pacing |
43647, 43648, 43881, 43882 |
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Laparoscopic Hiatal Hernia Repair |
43280, 43281, 43282 |
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Neurostimulators |
61860, 61863, 61867, 61885, 61886, 61889, 61891, 61892, 64553, 64555, 64561, 64566, 64568, 64581, 64590, 64596, 64597, 64598, 0587T, 0588T, 0786T, 0787T, 0816T, 0817T, 0818T, 0819T, 0908T, 0909T, 0910T, 0911T, 0912T, C1767, C1787, C9807, E0721, E0733, E0734, E0735, E0736, E0737, E0743, E0764, E0770, K1016, K1018, L8683, 0720T |
|
Obesity surgeries |
43631, 43632, 43633, 43634, 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 0312T, 0313T, 0314T, 0315T, 0316T, 0317T, 0813T, C9784, C9785 |
|
Oral orthognathic temporomandibular joint (TMJ) surgeries |
21010, 21050, 21060, 21070, 21085, 21100, 21116, 21125, 21127, 21141, 21142, 21143, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21206, 21208, 21210, 21215, 21240, 21242, 21243, 21244, 21247, 29800, 29804, 20910, |
| Penile implant | 54405, C2622 |
| Rhinoplasty | 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30468 |
| Surgical hyperhidrosis treatment | 32664 |
| Surgical nasal/sinus endoscopic procedures and balloon sinuplasty (Excludes diagnostic nasal/sinus endoscopies) | 31237, 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 31298, 33276, 33277, 33278, 33279, 33280, 33281, 33288, 69705, 69706, 93150, 93151, 93152, 93153, C9727, S2080 |
| Varicose vein: surgical treatment and sclerotherapy | 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 0524T |
Please note that issuance of an approval decision for any preauthorization request does not represent a guarantee of payment. Always refer to Humana’s official Preauthorization Lists (PAL) at www.humana.com/pal for the most up to date preauthorization requirements, coverage policies, and related plan policies.