Cigna Commercial Membership Clinical Guidelines
For Cigna Medicare membership guidelines click here.
Supplemental Information
High-Tech Imaging and Cardiology Guidelines
- Clinical Information to Establish Medical Necessity
- Preface to the Imaging Guidelines
- Site of Care: High-tech Radiology
General
- Abdomen Imaging Guidelines
- Breast Imaging Guidelines
- Cardiac Imaging Guidelines
- Chest Imaging Guidelines
- Head Imaging Guidelines
- Musculoskeletal Imaging Guidelines
- Neck Imaging Guidelines
- Oncology Imaging Guidelines
- Pacemaker (CID) Guidelines
- Pelvis Imaging Guidelines
- Peripheral Nerve Disease (PND) Imaging Guidelines
- Peripheral Vascular Disease (PVD) Imaging Guidelines
- Spine Imaging Guidelines
Pediatric
- Pediatric Abdomen Imaging Guidelines
- Pediatric and Special Populations Oncology Imaging Guidelines
- Pediatric Cardiac Imaging Guidelines
- Pediatric Chest Imaging Guidelines
- Pediatric Head Imaging Guidelines
- Pediatric Musculoskeletal Imaging Guidelines
- Pediatric Neck Imaging Guidelines
- Pediatric Pelvis Imaging Guidelines
- Pediatric Peripheral Nerve Disorders (PND) Imaging Guidelines
- Pediatric Peripheral Vascular Disease (PVD) Imaging Guidelines
- Pediatric Spine Imaging Guidelines
Radiation & Medical Oncology Guidelines
Radiation Oncology
Physician Worksheets
- Adrenal Cancer Physician Worksheet
- Anal Canal Cancer Worksheet
- Bile Duct Cancer Physician Worksheet
- Bladder Cancer Physician Worksheet
- Bone Metastases - Xofigo Physician worksheet
- Bone Metastases Physician Worksheet
- Brain Metastases Physician Worksheet
- Breast Cancer Physician Worksheet
- Central Nervous (CNS) Lymphoma Physician Worksheet
- Central Nervous (CNS) Neoplasm Physician Worksheet
- Cervical Cancer Physician Worksheet
- Endometrial Cancer Physician Worksheet
- Esophageal Cancer Physician Worksheet
- Extracranial Oligometastases Physician Worksheet
- Gallbladder Cancer Physician Worksheet
- Gastric Stomach Cancer Physician Worksheet
- Head and Neck Cancer Physician Worksheet
- Hepatobiliary Cancer Physician Worksheet
- Hodgkin's Lymphoma Physician Worksheet
- Hyperthermia Physician Worksheet
- Kidney Cancer Physician Worksheet
- Liver Cancer Physician Worksheet
- Liver Cancer, Selective Internal Radiation Therapy Physician Worksheet
- Lung Cancer, Small Cell Physician Worksheet
- Multiple Myeloma Physician Worksheet
- Non-Cancerous Diagnosis Physician Worksheet
- Non-Hodgkin's Lymphoma Physician Worksheet
- Non-Small Cell Lung Cancer Physician Worksheet
- Other Cancer Types Physician Worksheet
- Other Metastases (non-Bone/Brain) Physician Worksheet
- Pancreatic Cancer Physician Worksheet
- Prophylactic Cranial Irradiation (PCI) Radiation Therapy Physician Worksheet
- Prophylactic Cranial Irradiation (PCI) Radiation Therapy Physician Worksheet
- Prostate Cancer Physician Worksheet
- Radiopharmaceuticals Physician Worksheet
- Rectal Cancer Physician Worksheet
- Skin Cancer Physician Worksheet
- Soft Tissue Sarcoma Physician Worksheet
- Testicular Cancer Physician Worksheet
- Ureter/Urethral Cancer Physician Worksheet
- Vulva Cancer Physician Worksheet
Comprehensive Musculoskeletal Management Guidelines
- Clinical Information to Establish Medical Necessity
- Epidural Adhesiolysis (CMM-207) Guideline
- Epidural Steroid Injections (CMM-200) Guideline
- Facet Joint Injections/Medial Branch Blocks (CMM-201) Guideline
- Hip Replacement/Arthroplasty (CMM-313) Guideline
- Hip Surgery Arthroscopic and Open Procedures (CMM-314) Guideline
- Implantable Intrathecal Drug Delivery System (CMM-210) Guideline
- Interventional Pain Management Quick Reference Guide Guideline
- Joint Surgery Quick Reference Guide Guideline
- Knee Replacement Arthroplasty (CMM-311) Guideline
- Knee Surgery: Arthroscopic and Open Procedures (CMM-312) Guideline
- Preface to the Comprehensive Musculoskeletal Guidelines
- Prolotherapy (CMM-204) Guideline
- Radiofrequency Joint Ablations/Denervations (CMM-208) Guideline
- Regional Sympathetic Blocks (CMM-209) Guideline
- Sacroiliac Joint Procedures (CMM-203) Guideline
- Shoulder Arthroplasty/ Arthrodesis (CMM-318) Guideline
- Shoulder Surgery (CMM 315) Arthroscopic and Open Procedures Guideline
- Spinal Cord and Dorsal Root Ganglion Stimulation (CMM-211) Guideline
- Spinal Cord and Dorsal Root Ganglion Stimulation (CMM-211) Guideline - Effective 05/01/2024
Gastrointestinal Endoscopic Procedure Guidelines
Additional Information
Other Cigna guidelines and policies that may be relevant are available on the Cigna website.
For questions or comments regarding EviCore's Guidelines
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EviCore's clinical guidelines are evidence-based and apply to the following categories of service for individuals with Cigna-administered plans:
- Computed Tomography (CT) and Computed Tomography Angiography (CTA)
- Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA)
- Positron Emission Tomography (PET)
- Nuclear Cardiology
- Cardiac Stress Echocardiography
- Diagnostic Cardiac Catheterization
- Pain Management
- Major Joint Surgery
- Radiation Therapy (Oncology)
The terms of an individual's particular coverage plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD), or similar plan document] may differ significantly from the standard coverage plans upon which these guidelines are based. If these clinical guidelines are inconsistent with the terms of the individual's specific coverage plan, then the terms of the individual's coverage plan always takes precedence.
Coverage determinations in each specific instance require consideration of:
- The terms of the applicable coverage plan document in effect on the date of service
- Any applicable laws or regulations
- Any relevant collateral source materials including clinical guidelines
- The specific facts of the particular situation
EviCore's guidelines are based upon major national and international association and society guidelines and criteria, peer-reviewed literature, major treatises, and input from health plans, practicing academic and community-based physicians.
Medical technology is continuously evolving; the guidelines undergo a formal review annually, however EviCore reserves the right to change and update the guidelines without prior notice. Additional clinical guidelines may be developed as needed or may be withdrawn from use.
These guidelines are not intended to supersede or replace sound medical judgment, but instead should facilitate the identification of the most appropriate imaging procedure given the individual's clinical condition. These guidelines are written to cover medical conditions as experienced by the majority of individuals. However, these guidelines may not be applicable in certain clinical circumstances. EviCore's clinical guidelines may include information inapplicable to benefit plans administered by Cigna.
Clinical decisions, including treatment decisions, are the responsibility of the individual and his/her provider. Clinicians are expected to use independent medical judgment which takes into account the clinical circumstances to make individual management decisions.
EviCore supports the work of physicians and others who strive to reduce the overuse of diagnostic tests that are of low value, of no value, or where the risks of a given diagnostic test are greater than the benefits.
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