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Avera Health Plan: Commercial Guidelines

Overview

In this article, you can find Cohere guidelines for Avera Health Plan members with commercial coverage. Select a service below to download the applicable guideline.

Commercial Guidelines

Guidelines for all Services (Commercial)

Master Consolidated Policies

Commercial and Medicare Advantage

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Xenograft Implantation (Single Service).pdf
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Site of Service Criteria for Inpatient vs. Outpatient Services .pdf
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Right Heart Catheterization and_or Left Ventriculogram Guideline.pdf
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Myocardial Perfusion Imaging Single Photon Emission Computed Tomography (MPI-SPECT).pdf
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Left and Right Heart Catheterization Guideline.pdf
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Copy of Cohere Medical Policy - Coronary CTA (CCTA).pdf
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Cohere Medical Policy - Wireless Pulmonary Artery Pressure Monitoring (CardioMEMS).pdf
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Cohere Medical Policy - Vertebral Corpectomy.pdf
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Cohere Medical Policy - Vertebral Body Tethering.pdf
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Cohere Medical Policy - Venous Stenting.pdf
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Cohere Medical Policy - Transcatheter Mitral Valve Repair.pdf
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Cohere Medical Policy - Transcatheter Aortic Valve Replacement_Implantation (TAVR_TAVI).pdf
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Cohere Medical Policy - Total Disc Arthroplasty.pdf
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Cohere Medical Policy - Thoracolumbar Spinal Fusion With or Without Pelvic Fixation.pdf
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Cohere Medical Policy - Thermal Ablation of the Intraosseous Basivertebral Nerve (BVN).pdf
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Cohere Medical Policy - Subchondroplasty.pdf
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Cohere Medical Policy - Spinal Decompression (Laminectomy, Laminotomy, Foraminotomy, and Discectomy).pdf
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Cohere Medical Policy - Spinal Cord Stimulators.pdf
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Cohere Medical Policy - Sleep Study_Polysomnography (PSG).pdf
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Cohere Medical Policy - Shoulder Arthroscopy.pdf
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Cohere Medical Policy - Shoulder Arthroplasty.pdf
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Cohere Medical Policy - Sacroiliac Joint Injections and Radiofrequency Ablation (RFA).pdf
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Cohere Medical Policy - Sacroiliac Joint Fusion.pdf
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Cohere Medical Policy - Quantitative Computed Tomography (QCT), Bone Density.pdf
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Cohere Medical Policy - Proximal Tibial Osteotomy.pdf
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Cohere Medical Policy - Positron Emission Tomography (PET), PET_Computed Tomography (CT).pdf
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Cohere Medical Policy - Positron Emission Tomography (PET), Cardiac.pdf
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Cohere Medical Policy - Positron Emission Tomography (PET), Brain.pdf
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Cohere Medical Policy - PFO_ASD Closure.pdf
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Cohere Medical Policy - Peripheral Intravascular Lithotripsy (IVL).pdf
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Cohere Medical Policy - Peripheral Atherectomy, Non-Lower Extremity.pdf
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Cohere Medical Policy - Percutaneous Ventricular Assist Devices.pdf
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Cohere Medical Policy - Percutaneous Coronary Intervention.pdf
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Cohere Medical Policy - Pediatric Vertebral Body Tethering (VBT) and Vertical Expandable Prosthetic Titanium Rib (VEPTR) .pdf
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Cohere Medical Policy - Oral Appliance Therapy for Obstructive Sleep Apnea (OSA).pdf
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Cohere Medical Policy - Open Shoulder Surgical Procedures.pdf
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Cohere Medical Policy - Omnibus Codes (Musculoskeletal Care and Pain Management).pdf
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Cohere Medical Policy - Multiple Gated Acquisition (MUGA) Scan (3).pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Upper Extremity.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Temporomandibular Joint (TMJ).pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Spine.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Pelvis.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Neck_Orbit_Face.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Lower Extremity.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Chest.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Cardiac.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Brain.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Brain Functional.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Bone Marrow.pdf
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Cohere Medical Policy - Magnetic Resonance Imaging (MRI), Abdomen and Magnetic Resonance Cholangiopancreatography (MRCP).pdf
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Cohere Medical Policy - Magnetic Resonance Angiography (MRA), Upper Extremity .pdf
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Cohere Medical Policy - Magnetic Resonance Angiography (MRA), Spinal Canal.pdf
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Cohere Medical Policy - Magnetic Resonance Angiography (MRA), Neck.pdf
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Cohere Medical Policy - Magnetic Resonance Angiography (MRA), Lower Extremity.pdf
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Cohere Medical Policy - Magnetic Resonance Angiography (MRA), Head.pdf
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Cohere Medical Policy - Magnetic Resonance Angiography (MRA), Chest.pdf
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Cohere Medical Policy - Magnetic Resonance Angiography (MRA), Abdomen_Pelvis.pdf
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Cohere Medical Policy - Magnetic Resonance (MR) Spectroscopy.pdf
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Cohere Medical Policy - Magnetic Resonance (MR) Elastography.pdf
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Cohere Medical Policy - Lumbar Spinal Fusion (1).pdf
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Cohere Medical Policy - Lower Extremity Arterial Revascularization (1).pdf
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Cohere Medical Policy - Level of Care Criteria.pdf
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Cohere Medical Policy - Left Heart Catheterization .pdf
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Cohere Medical Policy - Left Atrial Appendage Implants.pdf
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Cohere Medical Policy - Leadless Cardiac Pacemakers.pdf
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Cohere Medical Policy - Kyphoplasty and Vertebroplasty.pdf
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Cohere Medical Policy - Kyphectomy.pdf
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Cohere Medical Policy - Knee Arthroscopy.pdf
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Cohere Medical Policy - Knee Arthroplasty.pdf
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Cohere Medical Policy - Intrathecal Pain Pumps.pdf
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Cohere Medical Policy - Intradiscal Biacuplasty, PIRFT, or IDET.pdf
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Cohere Medical Policy - Interspinous Process Devices Without Open Decompression.pdf
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Cohere Medical Policy - Interspinous Process Devices With Open Decompression.pdf
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Cohere Medical Policy - Interphalangeal Joint Arthroplasty.pdf
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Cohere Medical Policy - Internal Loop Recorders.pdf
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Cohere Medical Policy - Implantable Pulmonary Artery Pressure Sensors (IPAPS) for Heart Failure Management (1).pdf
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Cohere Medical Policy - Hip Core Decompression With or Without Bone Grafting.pdf
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Cohere Medical Policy - Hip Arthroscopy (1).pdf
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Cohere Medical Policy - Hip Arthroplasty (Partial, Total, or Revision).pdf
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Cohere Medical Policy - Hammertoe, Claw Toe, or Mallet Toe Surgical Treatment With or Without Fusion.pdf
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Cohere Medical Policy - Great Toe Surgical Treatments.pdf
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Cohere Medical Policy - Genicular Nerve Procedures.pdf
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Cohere Medical Policy - Gastric Pacing_Electrical Stimulation.pdf
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Cohere Medical Policy - Facet Joint Radiofrequency Ablation (RFA).pdf
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Cohere Medical Policy - Facet Joint Allograft Implants.pdf
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Cohere Medical Policy - Facet Injections .pdf
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Cohere Medical Policy - External Wearable Devices.pdf
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Cohere Medical Policy - External Cardiac Monitoring Devices.pdf
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Cohere Medical Policy - Esophagogastroduodenoscopy (EGD).pdf
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Cohere Medical Policy - Epidural Steroid Injections (ESIs).pdf
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Cohere Medical Policy - Electrophysiological Study (EPS).pdf
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Cohere Medical Policy - Descending Thoracic and Abdominal Aortic Aneurysm Repair.pdf
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Cohere Medical Policy - Coronary Intravascular Lithotripsy (IVL).pdf
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Cohere Medical Policy - Coronary Computed Tomography Angiography (CCTA), With or Without Fractional Flow Reserve (FFR) or Artificial Intelligence (AI) Plaque Analysis.pdf
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Cohere Medical Policy - Coronary Atherectomy.pdf
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Cohere Medical Policy - Computed Tomography Angiography (CTA), Upper Extremity.pdf
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Cohere Medical Policy - Computed Tomography Angiography (CTA), Neck.pdf
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Cohere Medical Policy - Computed Tomography Angiography (CTA), Lower Extremity.pdf
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Cohere Medical Policy - Computed Tomography Angiography (CTA), Head and Neck.pdf
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Cohere Medical Policy - Computed Tomography Angiography (CTA), Chest.pdf
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Cohere Medical Policy - Computed Tomography Angiography (CTA), Abdomen_Pelvis.pdf
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Cohere Medical Policy - Computed Tomography (CT), Upper Extremity .pdf
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Cohere Medical Policy - Computed Tomography (CT), Spine (Cervical, Thoracic, and Lumbar).pdf
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Cohere Medical Policy - Computed Tomography (CT), Orbit_Ear_Sella.pdf
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Cohere Medical Policy - Computed Tomography (CT), Neck (Soft Tissue).pdf
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Cohere Medical Policy - Computed Tomography (CT), Lower Extremity.pdf
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Cohere Medical Policy - Computed Tomography (CT), Face_Sinus.pdf
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Cohere Medical Policy - Computed Tomography (CT), Colonography.pdf
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Cohere Medical Policy - Computed Tomography (CT), Cerebral Perfusion Analysis.pdf
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Cohere Medical Policy - Computed Tomography (CT), Cardiac.pdf
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Cohere Medical Policy - Computed Tomography (CT), Brain.pdf
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Cohere Medical Policy - Cervical Spinal Fusion.pdf
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Cohere Medical Policy - Catheter-Based Angiogram, Lower Extremity Arteries.pdf
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Cohere Medical Policy - Category III CPT Codes.pdf
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Cohere Medical Policy - Carotid Sinus Stimulators.pdf
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Cohere Medical Policy - Carotid Endarterectomy (CEA).pdf
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Cohere Medical Policy - Carotid Artery Stenting (CAS) and_or Transcarotid Artery Revascularization (TCAR).pdf
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Cohere Medical Policy - Cardiac Implantable Rhythm Management Devices.pdf
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Cohere Medical Policy - Cardiac Implantable Devices.pdf
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Cohere Medical Policy - Cardiac Contractility Modulation (CCM).pdf
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Cohere Medical Policy - Cardiac Ablation .pdf
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Cohere Medical Policy - Bunionette Surgical Treatments.pdf
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Cohere Medical Policy - Bone Xenograft.pdf
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Cohere Medical Policy - Arterial Stenting, Other.pdf
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Cohere Medical Policy - Ankle Arthroplasty.pdf
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Cohere Medical Policy - Ankle Arthrodesis .pdf
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Cohere Medical Policy - Tarsometatarsal Arthrodesis.pdf
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Cohere Medical Policy - Obstructive Sleep Apnea Surgeries.pdf
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