Cohere Health’s Scope of Management, Cardiovascular and Endoscopy:
Prior Authorization List
Overview
Cohere Health, a patient journey optimization company, is designated the preauthorization and utilization management vendor for Humana’s diagnostic imaging, cardiology, endoscopy, and musculoskeletal services. Note: Cohere began managing musculoskeletal services in 2021 and 2022, and cardiology, and endoscopy in 2023.
Impacted Plans and Geographies
Impacted plans and geographies will include most Humana Medicare Advantage, some Commercial, and a subset of dual Medicare-Medicaid plans in all 50 states and the District of Columbia.
Clinical Scope
Practices must use Cohere when requesting preauthorization for any of the procedure codes or services listed in the table below.
For more information and to view the official and most up to date Humana Preauthorization List (PAL), please visit Humana’s provider website (www.humana.com/PAL). Please note, in addition to the procedure codes, other request criteria may impact submission requirements.
Use Cohere to obtain preauthorizations for the following procedure codes:
Please note: Several exclusions apply. For instance, Cohere will not be used for members with Medicare HMO policies in FL, CA, and HI. These members will continue to get authorizations through their primary care provider. Please contact Humana for more information.
Cardiology Services | Cardiology Services |
Service Category | Procedure Codes (HCPCS) |
Ablation | 93650, 93654, 93653, 93656 |
Cardiac Devices | 0408T, 0409T, 0410T, 0411T, 0413T, 0414T, 0415T, 0416T, 0417T, 0418T, 0571T, 0572T, 0573T, 0574T, 0580T, 0614T, 0823T, 0824T, 0825T, 0826T, 0915T, 0916T, 0917T, 0918T, 0919T, 0920T, 0921T, 0922T, 0923T, 0924T, 0925T, 0926T, 0927T, 0933T, 0934T, 0981T, 0982T, 0983T, 33206, 33207, 33208, 33210, 33211, 33212, 33213, 33214, 33216, 33217, 33221, 33224, 33227, 33228, 33229, 33230, 33231, 33233, 33234, 33235, 33240, 33241, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 33274, 33275, 33285, 33286, 33289, 33340, 93228, 93229, C1605, C1721, C1722, C1777, C1779, C1785, C1786, C1824, C1825, C1882, C1895, C1896, C1898, C1899, C1900, C2619, C2620, C2621, C2624 |
Cardiac Procedures/Surgeries | 0345T, 0716T, 0913T, 0914T, 33361, 33362, 33363, 33364, 33365, 33366, 33418, 33875, 33877, 33880, 33881, 33883, 33886, 34701, 34702, 34703, 34704, 34705, 34706, 34830, 34831, 34832, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 35301, 37215, 37216, 37217, 37218, 47133, 92920, 92928, 92924, 92933, 92937, 92943, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93580, 93593, 93594, 93595, 93596, 93597, C9600, C9602, C9604, C9607 |
Cardiac Imaging | 36245, 36246, 36247, 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 93350, 93351, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93355, 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93631, 93640, 93641, 93642, 93644, 0577T, A9611, C8925, C8926, C8927, C8928, C8930, C8931, C8932, C8933, C8934, C8935, C8936 |
Emerging technology/new indications for existing technology | 93264 |
Interventions (embolizations) | 37242, 37243 |
Peripheral Intravascular Lithotripsy | C9764, C9765, C9766, C9767, C9772, C9773, C9774, C9775, C1761, 92972 |
Peripheral Revascularization | 37236, 37238, 0505T, 0234T, 0235T, 0236T, 0237T, 0238T |
Other Durable Medical Equipment | G0555, 33225 |
Ventricular Assist Devices (VADs) | 33995, 33990, 33991 |
Endoscopy Services | Endoscopy Services |
Service Category | Procedure Codes (HCPCS) |
Diagnostic esophagogastroduodenoscopy (EGD) or esophagoscopy | 43191, 43193, 43197, 43198, 43200, 43202, 43235, 43239, 0652T, 0653T, 0654T |
Esophagogastroduodenoscopy (EGD) | 43235, 43237, 43238, 43239, 43242, 43252, 43253, 43259 |
Laparoscopic Hiatal Hernia Repair | 43280, 43281, 43282 |
Please note that issuance of an approval decision for any preauthorization request does not represent a guarantee of payment. Always refer to Humana’s official Preauthorization Lists (PAL) at www.humana.com/pal for the most up to date preauthorization requirements, coverage policies, and related plan policies.