Preface to the Comprehensive Musculoskeletal Guidelines

Applies only to imaging and procedures for musculoskeletal “symptoms and symptom complexes” listed in the CMM Guidelines (indications not listed may be redirected or require physician review), with CMS/Medicare and individual plan benefit rules superseding these Guidelines for Medicare enrollees. Prior authorization requires a recent consult and complete evaluation, detailed history/physical and prior treatment response, diagnostic testing with independent radiologist interpretation (discrepancies reconciled), justification and records for exceptions or sequential/non‑performed procedures, and accurate CPT/HCPCS coding that adheres to unit/level, mutually exclusive, add‑on, and other coding limitations (Category III codes allowed when appropriate).

"Quantity of Units/Levels: codes are not medically necessary if the medical information provided does not support the number of units requested or the number of levels requested."