Preface to the Comprehensive Musculoskeletal Guidelines

eviCore performs prior-authorization and medical-necessity reviews only for Comprehensive Musculoskeletal Management (CMM) services that match the clinical indications in the associated guideline, excluding procedures deemed experimental/investigational/unproven or out-of-scope (which are referred to the health plan) and deferring to health plan and CMS/Medicare policies (including CMS CED rules for approved trials). Authorization requires a recent consultation and complete evaluation with detailed history and exam, documentation of prior treatments and response, diagnostic testing (including advanced imaging with independent radiologist interpretation and reconciliation of any discrepancies), specialist/provider reports, and documentation of effect for sequential procedures or nonperformance when previously authorized.

"eviCore reviews only for the clinical indications listed in the associated guideline. Procedure code requests for a clinical indication not reviewed by eviCore will be directed to the health plan."