Avera Health Plan: Commercial Guidelines | Cohere Health Help Center

In this article, you can find Cohere guidelines for Avera Health Plan members with commercial coverage.

Cohere Commercial Guidelines for Avera Health Plan

Service

Ankle Arthrodesis - Version 3
Ankle Arthroplasty - Version 3
Arterial Stenting - Version 3
Bunionette Surgical Treatments - Version 3
Bone Xenograft - version 3
Cardiac Ablation - Version 3
Cardiac Contractility Modulation (CCM) - Version 2
Cardiac Implantable Devices - Version 4
Carotid Artery Stenting (CAS) and/or Transcarotid Artery Revascularization (TCAR) - Version 2
Carotid Endarterectomy (CEA) - Version 2
Carotid Sinus Stimulator - Version 1
Category III CPT Codes - version 3
Catheter-Based Angiogram - Lower Extremity Arteries - Version 3
Cervical Spinal Fusion - Version 4
Computed Tomography (CT) - Brain - Version 4
Computed Tomography (CT) - Cardiac - Version 5
Computed Tomography (CT) - Colonography - Version 4
Computed Tomography (CT) - Face/Sinus - Version 4
Computed Tomography (CT) - Lower Extremity - Version 5
Computed Tomography (CT) - Neck (Soft Tissue) - Version 4
Computed Tomography (CT) - Orbit/Ear/Sella - Version 4
Computed Tomography (CT) - Spine (Cervical, Thoracic, and Lumbar) - Version 5
Computed Tomography (CT) - Upper Extremity - Version 5
Computed Tomography Angiography (CTA) Abdomen/Pelvis including Lower Extremity RunOff - Version 4
Computed Tomography Angiography (CTA) Chest - Version 4
Computed Tomography Angiography (CTA) Head - Version 4
Computed Tomography Angiography (CTA) Lower Extremity - Version 4
Computed Tomography Angiography (CTA) Neck - Version 4
Computed Tomography Angiography (CTA) Upper Extremity - Version 4
Coronary Artery Atherectomy - Version 2
Coronary Artery Atherectomy and Intracoronary Lithotripsy Guideline - Version 2
Coronary Computed Tomography Angiography (CCTA) with or without Fractional Flow Reserve (FFR) - Version 2
Coronary Intravascular Lithotripsy (IVL) - Version 1
Descending Thoracic and Abdominal Aortic Repair - Version 2
Electrophysiological Study (EPS) - Version 2
Epidural Steroid Injections (ESI) - Version 4
External Wearable Devices - Version 4
Facet Joint Allograft Implants - Version 3
Facet Joint Injections - Version 4
Facet Joint Radiofrequency Ablation (RFA) - Version 4
Genicular Nerve Procedures - Version 3
Great Toe Surgical Treatments - Version 3
Hammertoe / Claw Toe / or Mallet Toe Surgical Treatment with or without Fusion - Version 3
Hip Arthroplasty - Version 4
Hip Arthroscopy - Version 5
Hip Core Decompression With or Without Bone Grafting (Single Service) - Version 2
Internal Loop Recorders - Version 5
Interphalangeal Joint Arthroplasty - Version 3
Interspinous Process Devices With Open Decompression - Version 3
Interspinous Process Devices Without Open Decompression - Version 5
Intradiscal Biacuplasty PIRFT or IDET - Version 3
Intrathecal Pain Pumps - Version 3
Knee Arthroplasty - Version 6
Knee Arthroscopy - Version 9
Kyphectomy - Version 4
Kyphoplasty and Vertebroplasty - Version 3
Leadless Cardiac Pacemakers - Version 2
Left and Right Heart Catheterization - Version 3
Left Atrial Appendage Implants - Version 3
Left Heart Catheterization - Version 4
Level of Care Criteria
Lower Extremity Arterial Revascularization - Version 3.1
Lumbar Spinal Fusion - Version 3
Magnetic Resonance (MR) Elastography - Version 3
Magnetic Resonance (MR) Spectroscopy - Version 3
Magnetic Resonance Angiography (MRA) Abdomen/Pelvis - Version 4
Magnetic Resonance Angiography (MRA) Chest - Version 4
Magnetic Resonance Angiography (MRA) Head - Version 4
Magnetic Resonance Angiography (MRA) Lower Extremity - Version 4
Magnetic Resonance Angiography (MRA) Neck - Version 4
Magnetic Resonance Angiography (MRA) Spinal Canal - Version 4
Magnetic Resonance Angiography (MRA) Upper Extremity - Version 4
Magnetic Resonance Imaging (MRI) Abdomen & Magnetic Resonance Cholangiopancreatography (MRCP) - Version 4
Magnetic Resonance Imaging (MRI) Bone Marrow - Version 5
Magnetic Resonance Imaging (MRI) Brain - Version 4
Magnetic Resonance Imaging (MRI) Brain Functional - Version 4
Magnetic Resonance Imaging (MRI) Cardiac - Version 5
Magnetic Resonance Imaging (MRI) Chest - Version 4
Magnetic Resonance Imaging (MRI) Lower Extremity - Version 5
Magnetic Resonance Imaging (MRI) Neck/Orbit/Face - Version 4
Magnetic Resonance Imaging (MRI) Pelvis - Version 3
Magnetic Resonance Imaging (MRI) Spine (Cervical Thoracic & Lumbar) - Version 5
Magnetic Resonance Imaging (MRI) Temporomandibular Joint (TMJ) - Version 4
Magnetic Resonance Imaging (MRI) Upper Extremity - Version 5
MUGA (Multiple Gated Acquisition Scan) - Version 2
Myocardial Perfusion Imaging Single Photon Emission Computed Tomography (MPI-SPECT) - Version 6
Patent Foramen Ovale (PFO) and Atrial Septal Defect (ASD) Closure - Version 2
Pediatric Vertebral Body Tethering - Version 2
Percutaneous Coronary Intervention (PCI)/Angioplasty/Stent - Version 2
Percutaneous Ventricular Assist Devices - Version 2
Peripheral Atherectomy, Non-Lower Extremity - Version 3
Peripheral Intravascular Lithortripsy (IVL) - Version 2
Positron Emission Tomography (PET) Brain - Version 4
Positron Emission Tomography (PET) Cardiac - Version 3
Positron Emission Tomography (PET)/PET-Computed Tomography (CT) - Version 6
Right Heart Catheterization and/or Left Ventriculogram - Version 3
Sacroiliac Joint (SIJ) Radiofrequency Ablation (RFA) - Version 5
Sacroiliac Joint Fusion - Version 3
Shoulder Arthroplasty - Version 4
Shoulder Arthroscopy - Version 5
Site of Service Criteria for Inpatient vs. Outpatient Services - Version 1
Spinal Cord Stimulators - Version 3
Spinal Decompression (Laminectomy /Laminotomy / Foraminotomy /and Discectomy) - Version 4
Subchondroplasty - Version 3
Tarsometatarsal Arthrodesis - Version 3
Thermal Ablation of the Intraosseous Basivertebral Nerve (BVN) - Version 3
Total Disc Arthroplasty - Version 3
Transcatheter Aortic Valve Replacement/Implantation (TAVR/TAVI) - Version 3
Transcatheter Mitral Valve Repair - Version 2
Venous Stenting - Version 3
Vertebral Body Tethering - Version 3
Vertebral Corpectomy - Version 4
Wireless Pulmonary Artery Pressure Monitoring (CardioMEMS) - Version 3.1
Xenograft Implantation - Version 2

Cohere Guidelines - All Specialties

HealthPartners: Cohere Medicare Advantage & Commercial/Medicaid Policies

Medical Mutual (MMO): Commercial & Medicare Advantage (MA) Guidelines

BlueCross BlueShield of Tennessee: Prior Authorization List (PAL) Codes Under Management (High Tech Imaging)

HealthPartners Prior Authorization List (PAL): Advanced Imaging Services