Preface to the Comprehensive Musculoskeletal Guidelines

eviCore covers evidence‑based medical necessity reviews for musculoskeletal procedures/services only when the request matches clinical indications listed in its Comprehensive Musculoskeletal Guidelines, excluding out‑of‑scope indications, procedures deemed experimental/investigational/unproven, duplicative requests, and requests governed by Medicare/CMS rules (CMS CED trials considered only where applicable). Prior authorization requires a recent consult and complete evaluation (detailed history and exam), documentation of prior treatment response, diagnostic imaging with independent radiologist interpretation and reconciliation of any clinically significant discrepancies, plus supporting records for exceptions, duplicate/similar or sequential procedures, noting that individual health plan coverage/eligibility may take precedence.

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