Cohere Health’s Scope of Management, Musculoskeletal: Prior Authorization List
Overview
Cohere Health, a patient journey optimization company, has been designated the exclusive preauthorization and utilization management vendor for Humana’s musculoskeletal (MSK) services in all 50 states and Washington, DC for most Commercials and Medicare plans.
Impacted Plans and Geographies
Impacted plans and geographies will include most Humana Commercial, Medicare Advantage, and dual Medicare-Medicaid plans in all 50 states and the District of Columbia.(1) This also includes patients with Author by Humana in South Carolina in the following counties: Berkeley, Charleston, Colleton, Dorchester, Anderson, Oconee, Pickens.
Clinical Scope
Practices must use Cohere when requesting preauthorizations 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 Prior Authorization 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:
Service | Procedure codes |
Epidural injections (outpatient only) | 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484, 64999 |
Facet injections | 64490, 64491, 64492, 64493, 64494, 64495, 64633, 64634, 64635, 64636, 64999, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T |
Foot surgeries: bunionectomy and hammertoe | 26535, 26536, 28110, 28240, 28285, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28306, 28308, 28310, 28740, 28750, L8641 |
Orthopedic surgeries: hip, knee and shoulder arthroplasty | 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27486, 27487, 29888 |
Orthopedic surgeries: hip, knee and shoulder arthroscopy | 23929, 27299, 27412, 27599, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29850, 29851, 29860, 29861, 29862, 29863, 29866, 29867, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29914, 29915, 29916, 29999, C9781, C8003, J7330 |
Pain infusion pump | 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 64999, C1772, C1891, C2626, C9804, C9806, E0782, E0783, E0785, E0786 |
Percutaneous Lumbar Intravertebral Disc Injection | 0627T, 0628T, 0629T, 0630T |
Physical, occupational and speech therapy (2) | 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97037, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97551, 97552, 97750, 97755, 97760, 97761, 97763, 97799, G0283, G0281 |
SI joint injections | 27096, 64454, 64624, 64625 |
Spinal cord stimulators | 0784T, 0785T, 63650, 63655, 63663, 63664, 63685, 63688, 64999, C1816, C1820, C1822, L8679, L8682 |
Spine Surgeries; Spinal fusion, decompression, kyphoplasty and vertebroplasty | 20999, 22100, 22101, 22102, 22103, 22510, 22511, 22512, 22513, 22514, 22515, 22526, 22527, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22836, 22837, 22838, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22856, 22857, 22858, 22859, 22860, 22861, 22862, 22867, 22868, 22869, 22870, 22899, 27278, 27279, 27280, 62287, 62330, 62331, 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, 64628, 64629, 0095T, 0098T, 0164T, 0165T, 0202T, 0219T, 0220T, 0221T, 0222T, 0274T, 0656T, 0657T, 0719T, 0790T, C1821, C2614, C9757 |
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 Prior Authorization Lists (PAL) at www.humana.com/pal for the most up to date prior authorization requirements, coverage policies, and related plan policies.
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.
Outpatient therapy performed in a skilled nursing facility or nursing home that is billed under the Medicare Part B benefit should be authorized through Cohere.