Introduction

Cohere Guidelines are created from an adaptation of peer-reviewed clinical research, medical society guidelines, and coordinated peer reviews. Medical Necessity Criteria and Site of Service Criteria are derived from this knowledge base within the guidelines and serve as a decision support tool to help approve prior authorizations for the most appropriate treatment, setting, and help assure consistency of care for each individual. These guidelines do not replace payer-specific policies, NCDs, or LCDs.

Cohere utilizes payer policy, national and local coverage determinations (NCDs and LCDs), and more in order to make an authorization determination. Please review the appropriate policies prior to submitting an authorization. When there are no NCDs or LCDs, our clinicians will use the Cohere guidelines found on this page for decisioning.

Cohere Medical Policies:

Cardiovascular Guidelines

Single Service Guidelines

Musculoskeletal/ Orthopedic Guidelines

Single Service Guidelines

Radiology Guidelines

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Angiography (MRA)

Computed Tomography (CT)

Computed Tomography Angiography (CTA)

Positron Emission Tomography (PET)

Single-Photon Emission Computerized Tomography (SPECT)

MPI SPECT

Other

Guidelines for Other Specialties

Other

Obstetrics and Gynecology

Laboratory Testing

Sleep Medicine

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

Otolaryngology (ENT)

Gastroenterology (GI)

Mental and Behavioral Health

Transcranial Magnetic Stimulation

Speech Language Pathology

Outpatient Speech Therapy

Cohere Medicare Advantage Policies:

Cardiovascular Guidelines

Line of Business	Service
Cohere Medicare Advantage Policy	Arterial Stenting
Cohere Medicare Advantage Policy	Cardiac Ablation
Cohere Medicare Advantage Policy	Cardiac Implantable Devices
Cohere Medicare Advantage Policy	Cardiac Catheterization
Cohere Medicare Advantage Policy	Carotid Artery Stenting (CAS) and/or Transcarotid Artery Revascularization (TCAR)
Cohere Medicare Advantage Policy	Carotid Artery Stenting (CAS) and/or Transcarotid Artery Revascularization (TCAR) without Distal Embolic Protection
Cohere Medicare Advantage Policy	Carotid Endarterectomy (CEA)
Cohere Medicare Advantage Policy	Catheter-Based Angiogram
Cohere Medicare Advantage Policy	Catheter-based Angiogram, Lower Extremity Arteries
Cohere Medicare Advantage Policy	Coronary Artery Atherectomy
Cohere Medicare Advantage Policy	Descending and Abdominal Aortic Aneurysm Repair
Cohere Medicare Advantage Policy	Electrophysiological Study (EPS)
Cohere Medicare Advantage Policy	Internal Loop Recorders
Cohere Medicare Advantage Policy	Leadless Cardiac Pacemakers
Cohere Medicare Advantage Policy	Left and Right Heart Catheterization
Cohere Medicare Advantage Policy	Left Heart Catheterization (Coronary Angiography and/or Bypass Angiography)
Cohere Medicare Advantage Policy	Left Atrial Appendage Implants
Cohere Medicare Advantage Policy	Lower Extremity Arterial Revascularization
Cohere Medicare Advantage Policy	Patent Foramen Ovale (PFO) and Atrial Septal Defect (ASD) Closure
Cohere Medicare Advantage Policy	Percutaneous Coronary Intervention/Angioplasty/Stent
Cohere Medicare Advantage Policy	Peripheral Intravascular Lithotripsy (IVL)
Cohere Medicare Advantage Policy	Right Heart Catheterization and/or Left Ventriculogram
Cohere Medicare Advantage Policy	Wireless Pulmonary Artery Pressure Monitoring (CardioMEMS)

Musculoskeletal/ Orthopedic Guidelines

Line of Business	Service
Cohere Medicare Advantage Policy	Ankle Arthrodesis
Cohere Medicare Advantage Policy	Ankle Arthroplasty
Cohere Medicare Advantage Policy	Bunionette Surgical Treatments
Cohere Medicare Advantage Policy	Cervical Spinal Fusion
Cohere Medicare Advantage Policy	Coronary intravascular Lithotripsy (IVL)
Cohere Medicare Advantage Policy	Facet Joint Allograft Arthroplasty
Cohere Medicare Advantage Policy	Genicular Nerve Procedures
Cohere Medicare Advantage Policy	Great Toe Surgical Treatments
Cohere Medicare Advantage Policy	Hammertoe, Claw Toe, or Mallet Toe Surgical Treatment with or without Fusion
Cohere Medicare Advantage Policy	Hip Arthroplasty
Cohere Medicare Advantage Policy	Hip Arthroscopy
Cohere Medicare Advantage Policy	Interphalangeal Joint Arthroplasty
Cohere Medicare Advantage Policy	Interspinous Process Devices with Decompression
Cohere Medicare Advantage Policy	Interspinous Process Devices without Decompression
Cohere Medicare Advantage Policy	Intradiscal Biacuplasty, PIRFT, or IDET
Cohere Medicare Advantage Policy	Intrathecal Pain Pumps
Cohere Medicare Advantage Policy	Knee Arthroplasty
Cohere Medicare Advantage Policy	Knee Arthroscopy
Cohere Medicare Advantage Policy	Kyphectomy
Cohere Medicare Advantage Policy	Laparoscopic Hiatal Hernia Repair and Anti-GERD Surgical Treatments
Cohere Medicare Advantage Policy	Lumbar Spinal Fusion
Cohere Medicare Advantage Policy	Sacroiliac Joint Fusion
Cohere Medicare Advantage Policy	Shoulder Arthroplasty
Cohere Medicare Advantage Policy	Shoulder Arthroscopy
Cohere Medicare Advantage Policy	Spinal Cord Stimulator
Cohere Medicare Advantage Policy	Spinal Decompression
Cohere Medicare Advantage Policy	Subchondroplasty
Cohere Medicare Advantage Policy	Tarsometatarsal Arthrodesis
Cohere Medicare Advantage Policy	Thermal Ablation of the Intraosseous Basivertebral Nerve
Cohere Medicare Advantage Policy	Total Disc Arthroplasty
Cohere Medicare Advantage Policy	Vertebral Body Tethering
Cohere Medicare Advantage Policy	Vertebral Corpectomy
Cohere Medicare Advantage Policy	Xenograft Implantation