Preface to the Comprehensive Musculoskeletal Guidelines

Applies prior authorization and utilization management to musculoskeletal procedures listed in the CMM Guidelines — covering listed indications (and CMS CED trials for Medicare/MA) while excluding out‑of‑scope indications, services considered experimental/investigational/unproven, and improperly coded, unbundled, mutually exclusive, or otherwise inconsistent code requests (unlisted CPT/HCPCS are treated as EIU unless a Category III or procedure‑specific guideline supports them). Key requirements include accurate CPT/HCPCS coding (use Category III when appropriate), submission of comprehensive documentation (recent consult/exam, treatment response, specified diagnostic tests with independent radiologist interpretation and reconciliation of discrepancies), and evidence for prior authorized, sequential, duplicate, or exception requests — failure to meet these coding or documentation rules may result in denial.

"Use of EviCore Clinical Decision Support Tool for common musculoskeletal symptoms and symptom complexes addressed in the CMM Guidelines."