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  3. Cohere Guidelines

Cohere Guidelines - All Specialties

Updated

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. 

Cohere Medical Policies:

Cardiovascular Guidelines

Care Path Guidelines

Single Service Guidelines


Musculoskeletal/ Orthopedic Guidelines

Care Path Guidelines

Single Service Guidelines

Radiology Guidelines

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Angiography (MRA)

Computed Tomography (CT)

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)

Otolaryngology (ENT)

Gastroenterology (GI)

Mental and Behavioral Health

Speech Language Pathology

 

Cohere Medicare Advantage Policies:

Cardiovascular Guidelines

Line of Business Service
Cohere Medicare Advantage Policy Cardiac Ablation
Cohere Medicare Advantage Policy Cardiac Implantable Devices 
Cohere Medicare Advantage Policy Carotid Artery Stenting (CAS) and/or Transcarotid Artery Revascularization (TCAR) 
Cohere Medicare Advantage Policy Carotid Artery Stenting (CAS) and/or Transcarotid Artery Revascularization (TCAR) without Distal Embolic Protection 
Cohere Medicare Advantage Policy Carotid Endarterectomy (CEA)
Cohere Medicare Advantage Policy Catheter-based Angiogram, Lower Extremity Arteries 
Cohere Medicare Advantage Policy Coronary Artery Atherectomy
Cohere Medicare Advantage Policy Descending Thoracic and Abdominal Aortic Repair
Cohere Medicare Advantage Policy Electrophysiological Study (EPS)
Cohere Medicare Advantage Policy Internal Loop Recorders
Cohere Medicare Advantage Policy Leadless Cardiac Pacemakers
Cohere Medicare Advantage Policy Left and Right Heart Catheterization 
Cohere Medicare Advantage Policy Left Heart Catheterization (Coronary Angiography and/or Bypass Angiography)
Cohere Medicare Advantage Policy Left Atrial Appendage Implants
Cohere Medicare Advantage Policy Lower Extremity Arterial Revascularization
Cohere Medicare Advantage Policy Patent Foramen Ovale (PFO) and Atrial Septal Defect (ASD) Closure 
Cohere Medicare Advantage Policy Percutaneous Coronary Intervention/Angioplasty/Stent
Cohere Medicare Advantage Policy Peripheral Intravascular Lithotripsy (IVL)
Cohere Medicare Advantage Policy

Right Heart Catheterization and/or Left Ventriculogram 
Cohere Medicare Advantage Policy Wireless Pulmonary Artery Pressure Monitoring (CardioMEMS)

 

Musculoskeletal/ Orthopedic Guidelines

Line of Business Service
Cohere Medicare Advantage Policy Ankle Arthrodesis
Cohere Medicare Advantage Policy Ankle Arthroplasty
Cohere Medicare Advantage Policy Bunionette Surgical Treatments
Cohere Medicare Advantage Policy Cervical Spinal Fusion
Cohere Medicare Advantage Policy

Coronary intravascular Lithotripsy (IVL)
Cohere Medicare Advantage Policy Facet Joint Allograft Arthroplasty
Cohere Medicare Advantage Policy Genicular Nerve Procedures
Cohere Medicare Advantage Policy Great Toe Surgical Treatments
Cohere Medicare Advantage Policy Hammertoe, Claw Toe, or Mallet Toe Surgical Treatment with or without Fusion
Cohere Medicare Advantage Policy Hip Arthroplasty
Cohere Medicare Advantage Policy Hip Arthroscopy
Cohere Medicare Advantage Policy Interphalangeal Joint Arthroplasty
Cohere Medicare Advantage Policy Interspinous Process Devices with Decompression
Cohere Medicare Advantage Policy Interspinous Process Devices without Decompression
Cohere Medicare Advantage Policy Intradiscal Biacuplasty, PIRFT, or IDET
Cohere Medicare Advantage Policy Intrathecal Pain Pumps
Cohere Medicare Advantage Policy Knee Arthroplasty
Cohere Medicare Advantage Policy Knee Arthroscopy
Cohere Medicare Advantage Policy Kyphectomy
Cohere Medicare Advantage Policy

Laparoscopic Hiatal Hernia Repair and Anti-GERD Surgical Treatments
Cohere Medicare Advantage Policy Lumbar Spinal Fusion
Cohere Medicare Advantage Policy Sacroiliac Joint Fusion
Cohere Medicare Advantage Policy Shoulder Arthroplasty
Cohere Medicare Advantage Policy Shoulder Arthroscopy
Cohere Medicare Advantage Policy Spinal Decompression
Cohere Medicare Advantage Policy Subchondroplasty
Cohere Medicare Advantage Policy Tarsometatarsal Arthrodesis
Cohere Medicare Advantage Policy Thermal Ablation of the Intraosseous Basivertebral Nerve
Cohere Medicare Advantage Policy Total Disc Arthroplasty
Cohere Medicare Advantage Policy Vertebral Body Tethering
Cohere Medicare Advantage Policy Vertebral Corpectomy
Cohere Medicare Advantage Policy Xenograft Implantation

 

Radiology Guidelines

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Angiography (MRA)

Computed Tomography (CT)

Computed Tomography Angiography (CTA)

Positron Emission Tomography (PET)

Single-Photon Emission Computerized Tomography (SPECT)

Cardio

Gastroenterology (GI)

3D Imaging

Guidelines for Other Specialties

 
Sleep Medicine

State Specific Medicaid Policies:

Radiology Guidelines

Magnetic Resonance Imaging (MRI)

Computed Tomography (CT)

Commercial & Medicare Advantage Policies:

Site of Service Criteria for Inpatient vs. Outpatient Services

 

Line of Business Service
Commercial & Medicare Advantage Site of Service Criteria for Inpatient vs. Outpatient Services

 

 

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