Preface to the Comprehensive Musculoskeletal Guidelines

EviCore authorizes musculoskeletal procedures only for clinical indications listed in its Comprehensive Musculoskeletal Management (CMM) Guidelines and may exclude procedures not listed or deemed experimental/investigational, with health plan and CMS coverage (including CMS CED rules) taking precedence. Prior authorization requires a recent consult and complete evaluation (detailed history and exam), documentation of prior treatment response and effects for sequential/duplicate procedures, required diagnostic testing including advanced imaging with independent radiologist interpretation (and reconciliation of significant discrepancies), and submission of medical records to justify any exceptions or nonperformance of prior authorizations.

"Musculoskeletal procedures/services for common symptoms and symptom complexes as addressed in the Comprehensive Musculoskeletal Management (CMM) Guidelines (the Clinical Decision Support Tool addre..."