Introduction
Cohere Guidelines are created from an adaptation of peer-reviewed clinical research, medical society guidelines, and coordinated peer reviews. Medical Necessity Criteria and Site of Service Criteria are derived from this knowledge base within the guidelines and serve as a decision support tool to help approve prior authorizations for the most appropriate treatment, setting, and help assure consistency of care for each individual. These guidelines do not replace payer-specific policies, NCDs, or LCDs.
Cohere utilizes payer policy, national and local coverage determinations (NCDs and LCDs), and more in order to make an authorization determination. Please review the appropriate policies prior to submitting an authorization. When there are no NCDs or LCDs, our clinicians will use the Cohere guidelines found on this page for decisioning.
Cardiovascular Guidelines
Care Path Guidelines
- Atrial Fibrillation
- Chest Pain
- Coronary Artery Disease
- Atrial Flutter
- Syncope and Presyncope
- Palpitations Guidelines
- Stroke or TIA (within 6 months)
- Stroke or TIA (more than 6 months ago or never)
- Cardiomyopathies
- Shortness of Breath
- Murmurs
- Pericardial Disorder
- Pre-Operative Evaluations
- Adult Congenital Heart Disease
- Valvular Heart Disease
- Ventricular Arrhythmias
- Supraventricular Tachycardia
- Sinus Node Dysfunction
- Aortic Disease
- Heart Block
- Peripheral Arterial Disease
- Peripheral Venous Disease
Single Service Guidelines
- Internal Loop Recorder
- Left and Right Heart Catheterization
- Left Heart Catheterization
- Myocardial Perfusion Imaging Single Photon Emission Computed Tomography (MPI-SPECT)
- Right Heart Catheterization and/or Left Ventriculogram
- Stress Echocardiogram
- Transesophageal Echocardiography (TEE)
- Transthoracic Ecocardiogram (TTE)
- External Wearable Device
- Coronary Artery Atherectomy
- Carotid Sinus Stimulators
- Leadless Cardiac Pacemakers
- Pulmonary Artery Denervation
- Arterial Stenting
- Peripheral Atherectomy, Non-Lower Extremity
- Venous Stents
- Pneumatic Compressors and Appliances
- Left Atrial Appendage Implants
- Multiple Gated Acquisition (MUGA) Scan
- Magnetic Resonance Imaging (MRI), Cardiac
- Percutaneous Coronary Intervention (PCI)/Angioplasty/Stent
- Percutaneous Ventricular Assist Devices
- Cardiac Ablation
- Cardiac Implantable Devices
- Coronary intravascular Lithotripsy (IVL)
- Wireless Pulmonary Artery Pressure Monitoring (CardioMEMS)
- Peripheral Intravascular Lithotripsy (IVL)
- Transcatheter Mitral Valve Repair
- Carotid Endarterectomy (CEA)
- Patent Foramen Ovale (PFO) and Atrial Septal Defect (ASD) Closure
- Transcatheter Aortic Valve Replacement (TAVR)
- Electrophysiological Study (EPS)
- Carotid Artery Stending (CAS) and/or Transcarotid Artery Revascularization (TCAR)
- Catheter-Based Angiogram, Lower Extremeties
- Descending Thoracic and Abdominal Aortic Repair
- Lower Extremity Arterial Revascularization
- Wearable Defibrillators
Musculoskeletal/ Orthopedic Guidelines
Care Path Guidelines
- Femoral Head Osteonecrosis
- General Hip Pain
- Hip - Labral Injuries and Femoroacetubular Impingement (FAI)
- Hip Arthritis
- Knee Cartilage Disorders
- General Knee Pain
- Knee Ligament Injury
- Knee Arthritis
- Knee Tendon Injury
- AC Joint Injury & Arthritis
- General Shoulder Pain
- Adhesive Capsulitis
- Shoulder Arthritis
- Biceps Tendon Injury
- Shoulder Fractures
- Labral Injuries
- Pectoralis Major Tear
- Rotator Cuff Injuries
- Cervical Myelopathy
- Cervical Radiculopathy
- Neck Pain
- Low Back Pain
- Lumbar Radiculopathy
- Lumbar Spinal Stenosis
- Forefoot Deformities
- Hallux Valgus, Hallux Rigidus, Bunionette
Single Service Guidelines
- Epidural Steroid Injections (ESI)
- Facet Joint Injections
- Sacroiliac (SI) Joint Injections
- Physical and Occupational Therapy
- Total Shoulder Arthroplasty
- Shoulder Arthroscopy
- Hip Arthroplasty
- Hip Arthroscopy
- Knee Arthroplasty
- Knee Arthroscopy
- Enzyme Injection for Dupuytren's Contracture (XIAFLEX®)
- Genicular Nerve Procedures
- Sacroiliac Joint (SIJ) Radiofrequency Ablation (RFA)
- Spinal Cord Stimulator
- Kyphoplasty and Vertebroplasty
- Spinal Allogeneic Tissue-Based Injections
- Ankle Arthrodesis
- Ankle Arthroplasty
- Intrathecal Pain Pumps
- Spinal Decompression
- Thermal Ablation of the Intraosseous Basivertebral Nerve (BVN)
- Cervical Spinal Fusion
- Lumbar Spinal Fusion
- Vertebral Corpectomy
- Facet Joint Allograft Implants
- Total Disc Arthroplasty
- Vertebral Body Tethering
- Kyphectomy
- Xenograft Implantation
- Facet Joint Radiofrequency Ablation (RFA)
- Subchondroplasty
- Carpal Tunnel Release
- Knee Manipulation Under Anesthesia
- Negative Pressure Wound Therapy
- Bone Growth Stimulators
- Sacroiliac Joint Fusion
- Chiropractic Manipulative Treatment
- Intradiscal Biacuplasty, PIRFT, or IDET
- Interspinous Process Devices with Open Decompression
- Interspinous Process Devices without Open Decompression
- Open Shoulder Surgical Procedures
- Proximal Tibial Osteotomy
- Open Meniscus Repair
- Viscosupplementation
- Interphalangeal Joint Arthroplasty
- Hammertoe, Claw Toe, or Mallet Toe Surgical Treatment with or without Fusion
- Bunionette Surgical Treatments
- Great Toe Surgical Treatments
- Tarsometatarsal Arthrodesis
- Shoulder Manipulation under Anesthesia
- Patellofemoral Reconstruction/realignment
- Knee Open or Arthroscopic Prepatellar Bursectomy
- Hip Core Decompression with or without Bone Grafting
- Periacetabular Osteotomy/Surgical Dislocation
- Shoulder Tenodesis/Tenotomy
Radiology Guidelines
Magnetic Resonance Imaging (MRI)
- Cardiac
- Chest
- Neck/Orbit/Face
- Brain
- Brain (Functional)
- Upper Extremity
- Bone Marrow, Whole Body
- Lower Extremity
- Abdomen and MRCP
- Pelvis
- Breast
- TMJ
- Spine (Cervical, Thoracic, and Lumbar)
- MR Spectroscopy
- MR Elastography
Magnetic Resonance Angiography (MRA)
Computed Tomography (CT)
- Cardiac
- Chest
- Orbit/Ear/Sella
- Face/Sinuses
- Brain
- Spine (Cervical, Thoracic, Lumbar)
- Abdominal/Pelvic
- Upper Extremity
- Lower Extremity
- Colonography
- Neck
Computed Tomography Angiography (CTA)
Positron Emission Tomography (PET)
Single-Photon Emission Computerized Tomography (SPECT)
Other
Guidelines for Other Specialties
Obstetrics and Gynecology
Laboratory Testing
Sleep Medicine
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
- Manual Wheelchairs
- Power Mobility Device (PMD) (Power Operated Vehicles (POVs) and Power Wheelchairs (PWCs)) and Accessories
- Cranial Remodeling Orthotic Devices
Otolaryngology (ENT)
Gastroenterology (GI)
Mental and Behavioral Health
Speech Language Pathology
|
|