Preface to the Comprehensive Musculoskeletal Guidelines

EviCore only reviews and authorizes procedures for the clinical indications listed in its Comprehensive Musculoskeletal Management guidelines (effective 11/1/2024), generally treats unlisted CPT/HCPCS codes as experimental/investigational unless noted, and defers to health plan/CMS coverage policies (including CMS CED trial requirements) which take precedence. Prior authorization requires full clinical documentation—recent consultation, detailed history and exam, prior treatment response, required diagnostic testing with independent radiologist interpretation, and specific documentation for sequential/duplicate or exception requests.

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