Overview FAQs
You may see messages within the Cohere portal stating that your request is missing information, and the request is "pending". This article is intended to help you correct that and prevent future pending!
In the cases where our portal cannot auto-approve your request, our clinical team will review it against guidelines and policies and reach out by phone as needed to request more information.
Please click on the links below to view the specific pending messages, policies, clinical attachments that are required for this service:
There are 2 main reasons why all requests pend:
There is no clinical documentation included
If you have any questions about the type of documents that should be included with Facet Injection requests, check out this great resource! We have combed through the policy for you and pulled out the important requirements.
Attached clinical documentation does not support the criteria required by policy
Documentation with vague descriptions or omissions can result in the need for a peer-to-peer consult or a denial of the authorization request. The list below outlines the thoroughness that is needed for our technology and clinical reviewers to approve authorizations.
View a printable version of this list to share with others at your organization
Conservative Care Requirements
Below we have included the possible pend messages and the specific requirements that may surface in the portal as a result of inadequate, or lack of, conservative care.
This request pended because Commercial and Medicare coverage require that specific conservative care measures must be attempted before a facet injection. This includes: Lifestyle Modifications, Medications, Physical Therapy, or Home exercise.
What this means for you: For both Commercial and Medicare requests we must be able to identify all types of conservative care that were attempted prior to requesting the facet injection.
This request pended for review because Commercial and Medicare coverage require a minimum of 12 weeks of conservative care prior to Facet Injections.
What this means for you: For both Commercial and Medicare requests we must be able to identify a clear timeline of conservative care with specific dates.
Facet Injection Prerequisites
Below we have included the possible pend messages and the specific requirements that may surface in the portal as a result of inadequate, or lack of, required prerequisites for facet injections.
This request pended for review because the patient's symptoms are not exacerbated by movement of the spine as outlined by Commercial coverage.
This request pended for review because the patient has non-facet-related pain, which is not covered by Medicare coverage.
Policy limitations / Contraindications
Below we have included the possible pend messages and the specific requirements that may surface in the portal as a result of policy limitations or if there are identified contraindications.
This request pended for review because Intra-articular facet blocks require specific justification according to Medicare coverage.
What this means for you: This type of service will always require manual review by our clinical team.
This request pended for review because it is for therapeutic facet injections to treat pain, which is not covered by Commercial coverage. OR This request pended because there is a documented indication to performing a facet injection that is not covered according to Commercial and Medicare coverage. OR This request pended because there is a documented indication to perform an RFA that is not covered according to Commercial and Medicare coverage.
What this means for you: This type of request will always likely pend for review and be denied due to coverage limitations.
This request pended for review because answers to the clinical assessment question and/ or the procedure codes require that this request go through manual review by our clinical team.
What this means for you: This request will likely always pend for review.
This request pended for review because clinical findings suggest that this type of service may not be appropriate.
RFA Prerequisites
Below we have included the possible pend messages and the specific requirements that may surface in the portal as a result of inadequate, or lack of, policy-required prerequisites for RFAs.
This request pended because Commercial and Medicare coverage do not cover RFAs without at least 80% relief from two diagnostic medial branch blocks (MBB's).
What this means for you: For both Commercial and Medicare requests, prior to RFA requests, two medial branch blocks must be attempted with documentation that clearly states at least 80% relief. If this is not available, your request may be denied.
This request pended because Commercial and Medicare coverage does not cover repeat RFAs without 50% pain relief from previous RFA.
What this means for you: For both Commercial and Medicare requests you will need documentation that clearly states at least 50% pain relief from previous RFA’s. If this is not available, your request may be denied.
Subsequent Injection Requirements
Below we have included the possible pend messages and the specific requirements that may surface in the portal as a result of requesting additional or subsequent injections.
This request pended because Commercial and Medicare coverage do not cover subsequent facet injections without at least 80% relief from an initial injection. OR This request pended because Medicare coverage does not cover subsequent therapeutic facet injections without 50% pain relief from previous injections.
What this means for you: For some policies, you will need documentation that clearly states at specific pain reduction. If this is not available, your request may be denied.
Units / Levels / Frequency
Below we have included the possible pend messages and the specific requirements that may surface in the portal as a result of issues with units, levels, or frequency of facet injection requests.
This request pended because Medicare coverage does not cover this therapeutic facet injections without 80% relief from 2 previous diagnostic injections.
What this means for you: For Medicare requests you will need documentation that clearly states at least 80% pain relief from 2 previous diagnostic injections.
This request pended because more than the coverage limit was requested for facet injections OR for RFA:
What this means for you: For Commercial requests, you cannot request more than 3 levels. For Medicare requests, you cannot request more than 2 levels.
This request pended because x4 facet injections at the same facet joint level in a 12 month timeframe is the maximum covered by Medicare coverage. OR This request pended because x2 RFAs at the same facet joint level in a 12 month timeframe is the maximum covered by Commercial and Medicare.
What this means for you: If you exceed the number of procedures indicated, this request may pend fro review and be denied due to coverage limitations.
This request pended because more than 1 service date has been requested.
What this means for you: This type of request is limited to a one-time visit, which is reflected in the “Number of Service Dates” field.
What if this is all the information you have?
If this is all the information you have, you will likely need to reach out to the requesting provider in order to obtain the necessary clinical details and documentation.
What if you believe the information for this requirement was missed?
If this is the case, you will likely receive a phone call from us in order to better understand the location and specific details of the information we determined to be missing.
Where can I find more details about the specifics of these policies?
We have created payer-specific resources that can direct you to specific language and comprehensive checklists of all the documentation needed for this type of documentation. Click here to learn more.
How do I address the specific pending message I received?
In each category below, you will see an interpretation of all pend messages you may receive, and give you clear details about the kind of documentation that is required for this request. Doing this can resolve current pends as well as prevent pending requests in the future!