Cohere Health Help Center

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

Written by Nicole Saidai

February 2, 2026

In this article, you can find Cohere guidelines for Medical Mutual (MMO) members with the following coverage:

Commercial
Medicare Advantage

Cohere Guidlines: Commercial	Cohere Guidlines: Commercial
Line of Business	Service
Commercial	3D Rendering of Imaging Studies – version 2 Arterial Stenting, Other – version 3 Capsule Endoscopy – version 2 Cardiac Ablation – version 3 Cardiac Catheterization - version 1 Cardiac Contractility Modulation (CCM) – version 2 Cardiac Implantable Devices – version 2 Carotid Artery Stenting (CAS) and/or Transcarotid Artery Revascularization (TCAR) – version 2 Carotid Endarterectomy (CEA) – version 2 Carotid Sinus Stimulators – version 2 Category III CPT codes - version 3 Catheter-Based Angiogram, Lower Extremity Arteries – version 3 Chiropractic Treatment – version 2 Computed Tomography (CT) Abdomen/Pelvis – version 4 Computed Tomography (CT) Brain – version 4 Computed Tomography (CT) Cardiac – version 5 Computed Tomography (CT) Chest – version 4 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 - 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 Computed Tomography Angiography (CCTA) with or without Fractional Flow Reserve (FFR) – version 3 Coronary Intravascular Lithotripsy (IVL) – version 2 Descending Thoracic and Abdominal Aortic Repair – version 2 Diaphragmatic/Phrenic Nerve Electrical Stimulators - Version 1 Electrophysiological Study (EPS) – version 2 Esophagogastroduodenoscopy (EGD) – version 2 External Wearable Devices - version 4 Gastric Pacing/Electrical Stimulation – version 1 Hypoglossal Nerve Stimulation (HGNS) Implantable Devices - Version 2 Internal Loop Recorders – version 5 Knee Arthroscopy - version 9 Laparoscopic Hiatal Hernia Repair and Anti-GERD Surgical Treatments - Version 2 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 Low-Dose Computed Tomography (LDCT) Chest for Lung Cancer Screening – version 2 Lower Extremity Arterial Revascularization – version 3.1 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 and 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 3 Magnetic Resonance Imaging (MRI) Breast – version 4 Magnetic Resonance Imaging (MRI) Cardiac – version 5 Magnetic Resonance Imaging (MRI) Chest – version 4 Magnetic Resonance Imaging (MRI) Fetal/Placental – version 2 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 Multiple Gated Acquisition (MUGA) – version 2 Myocardial Perfusion Imaging Single Photon Emission Computed Tomography (MPI-SPECT) – version 6 Obstructive Sleep Apnea Surgeries (Non-Covered Procedures) – version 1 Oral Appliance Therapy for Sleep Apnea (OSA) – version 2 Outpatient Speech Therapy – version 3 Patent Foramen Ovale (PFO) and Atrial Septal Defect (ASD) Closure – version 2 Percutaneous Coronary Intervention / Angioplasty / Stent – version 2 Percutaneous Ventricular Assist Devices – version 2 Peripheral Atherectomy, Non-Lower Extremity – version 3 Peripheral Intravascular Lithotripsy (IVL) – version 2 Physical and Occupational Therapy (PT/OT) – version 5 Positive Pressure Ventilation – version 1 Positron Emission Tomography (PET), Brain – version 4 Positron Emission Tomography (PET) Cardiac – version 3 Positron Emission Tomography (PET)/PET-Computed Tomography (CT) – version 6 Proximal Tibial Osteotomy - version 3 Right Heart Catheterization and/or Left Ventriculogram – version 3 Sacroiliac Joint Injections and Radiofrequency Ablation (RFA) - version 5 Sleep Study / Polysomnography (PSG) – version 1 Transcatheter Mitral Valve Repair – version 2 Venous Stenting – version 2 Wearable Defibrillators – version 2.1 Wireless Pulmonary Artery Pressure Monitoring (CardioMEMS) – version 3

Cohere Guidelines: Medicare Advantage (MA)	Cohere Guidelines: Medicare Advantage (MA)
Line of Business	Service
Medicare Advantage (MA)	3D Imaging - version 1 Arterial Stenting - version 1 Capsule Endoscopy - version 1.2 Cardiac Ablation - version 3 Cardiac Catheterization - version 1 Cardiac Contractility Modulation (CCM) - version 2 Cardiac Implantable Devices - version 3 Carotid Artery Stenting (CAS) and/or Transcarotid Artery Revascularization (TCAR) - version 3 Carotid Endarterectomy (CEA) - version 1 Category III CPT Codes - version 2 Catheter-Based Angiogram - version 3 Computed Tomography (CT) Computed Tomography (CT) Abdomen/Pelvis - version 2 Computed Tomography (CT) Brain - version 2 Computed Tomography (CT) Cardiac - version 3 Computed Tomography (CT) Chest - version 2 Computed Tomography (CT) Colonography - version 2 Computed Tomography (CT) Face/Sinus - version 2 Computed Tomography (CT) Neck (Soft Tissue) - version 2.1 Computed Tomography (CT) Orbit, Ear, Sella - version 2.1 Computed Tomography (CT) Spine (Cervical Thoracic and Lumbar) - version 2.1 Computed Tomography (CT) Upper Extremity - version 2 Computed Tomography (CT), Lower Extremity - version 2 Computed Tomography Angiography (CTA) Computed Tomography Angiography (CTA) Abdomen/Pelvis including Lower Extremity RunOff - version 2 Computed Tomography Angiography (CTA) Chest - version 2 Computed Tomography Angiography (CTA) Head - version 2 Computed Tomography Angiography (CTA) Lower Extremity - version 2 Computed Tomography Angiography (CTA) Neck - version 2 Computed Tomography Angiography (CTA) Upper Extremity - version 2 Coronary Artery Atherectomy - version 3 Coronary Computed Tomography Angiography (CCTA) with or without Fractional Flow Reserve (FFR) - version 2 Coronary Intravascular Lithotripsy (IVL) - Version 1 Descending and Abdominal Aortic Aneurysm Repair - version 3 Diaphragmatic/Phrenic Nerve Electrical Stimulators - Version 1 Electrophysiological Study (EPS) - version 1 Esophagogastroduodenoscopy (EGD) - version 2.1 Gastric Pacing/Electrical Stimulation - version 1.1 Home Physical and Occupational Therapy (PT/OT) - version 1.1 Hypoglossal Nerve Stimulation (HGNS) Implantable Devices - Version 3 Internal Loop Recorders - version 1 Laparoscopic Hiatal Hernia Repair and Anti-GERD Surgical Treatments - Version 2 Leadless Cardiac Pacemakers - version 3 Left and Right Heart Catheterization- version 2.1 Left Heart Catheterization, Coronary Angiography and/or Bypass Angiography - version 2.1 Low-Dose Computed Tomography (LDCT) Chest for Lung Cancer Screening - version 2 Lower Extremity Arterial Revascularization - version 1 Magnetic Resonance (MR) Magnetic Resonance (MR) Elastography - version 2 MR Spectroscopy - version 2 Magnetic Resonance Angiography (MRA) Magnetic Resonance Angiography (MRA) Abdomen/Pelvis - version 2 Magnetic Resonance Angiography (MRA) Chest - version 2 Magnetic Resonance Angiography (MRA) Head - version 2 Magnetic Resonance Angiography (MRA) Lower Extremity - version 2 Magnetic Resonance Angiography (MRA) Neck - version 2 Magnetic Resonance Angiography (MRA) Spinal Canal - version 2 Magnetic Resonance Angiography (MRA) Upper Extremity - version 2 Magnetic Resonance Imaging (MRI) Magnetic Resonance Imaging (MRI) Abdomen and Magnetic Resonance Cholangiopancreatography (MRCP) - version 2 Magnetic Resonance Imaging (MRI) Bone Marrow - version 2 Magnetic Resonance Imaging (MRI) Brain - version 2 Magnetic Resonance Imaging (MRI) Brain Functional - version 2 Magnetic Resonance Imaging (MRI) Breast - version 2 Magnetic Resonance Imaging (MRI) Cardiac - version 2 Magnetic Resonance Imaging (MRI) Chest - version 2 Magnetic Resonance Imaging (MRI) Fetal/Placental - version 2 Magnetic Resonance Imaging (MRI) Lower Extremity - version 2 Magnetic Resonance Imaging (MRI) Neck/Orbit/Face - version 2 Magnetic Resonance Imaging (MRI) Pelvis - version 2 Magnetic Resonance Imaging (MRI) Spine (Cervical /Thoracic) - version 2 Magnetic Resonance Imaging (MRI) Spine (Lumbar) - version 1.1 Magnetic Resonance Imaging (MRI) Temporomandibular Joint (TMJ) - version 2.1 Magnetic Resonance Imaging (MRI) Upper Extremity - version 2 Multiple Gated Acquisition (MUGA) Scan - Version 2 Myocardial Perfusion Imaging Single Photon Emission Computed Tomography (MPI-SPECT) - Version 2 Obstructive Sleep Apnea Surgeries (non-covered) - version 1.1 Outpatient Speech Therapy - version 1.1 Oral Appliances for Obstructive Sleep Apnea - version 1 Patent Foramen Ovale (PFO) and Atrial Septal Defect (ASD) closure - version 3 Percutaneous Coronary Intervention_Angioplasty_Stent - version 3 Percutaneous Ventricular Assist Devices - version 1 Peripheral Intravascular Lithotripsy (IVL) - Version 1 Physical and Occupational Therapy (PT/OT) – version 1 Positive Pressure Ventilation - version 1 Positron Emission Tomography (PET) Positron Emission Tomography (PET) Brain - version 2 Positron Emission Tomography (PET) Cardiac - version 2 Positron Emission Tomography (PET) - Computed Tomography (CT) - version 3 Right Heart Catheterization and/or Left Ventriculogram- version 2 Sacroiliac Joint Fusion - version 3.2 Sleep Study/Polysomnography (PSG) - version 4 Spinal Cord Stimulators - version 1.1 Stress Echocardiogram - version 2.1 Transthoracic Echocardiogram (TTE) - version 2

Cohere Guidlines: Commercial & Medicare Advantage (MA)	Cohere Guidlines: Commercial & Medicare Advantage (MA)
Line of Business	Service
Commercial & Medicare Advantage (MA)	Site of Service Criteria for Inpatient vs. Outpatient Services - version 1

Related Articles

Cohere Guidelines - All Specialties

Avera Health Plan: Commercial Guidelines

HealthPartners: Cohere Medicare Advantage & Commercial/Medicaid Policies

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

HealthPartners Prior Authorization List (PAL): Advanced Imaging Services