Preface to the Comprehensive Musculoskeletal Guidelines

eviCore reviews medical necessity only for Comprehensive Musculoskeletal Management services and clinical indications explicitly listed in its associated guidelines, excluding indications not listed, investigational/experimental (EIU) procedures, and requests governed by payer/CMS coverage (CMS/Medicare policies supersede eviCore; clinical trial procedures require CMS/payor approval). Prior authorization requires a recent consult and comprehensive evaluation, documentation of prior treatment response, required diagnostic testing with independent radiologist interpretation (and reconciliation of significant discrepancies), relevant specialist reports, and additional records for sequential/duplicate requests or exceptions to guideline criteria.

"Requests for procedures/services for the clinical indications listed in the associated guideline (eviCore reviews only the clinical indications listed in the associated guideline)."