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Cigna Commercial Membership Clinical Guidelines
For Cigna Medicare membership guidelines click here.
Supplemental Information
Comprehensive Musculoskeletal Management Guidelines
- Interventional Pain Management Quick Reference Guide Guideline
- Joint Surgery Quick Reference Guide Guideline
- Preface to the Comprehensive Musculoskeletal Guidelines
Interventional Pain and Joint Surgery
- Ablations/Denervations of Facet Joints and Peripheral Nerves (CMM-208) Guideline
- 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
- Knee Replacement Arthroplasty (CMM-311) Guideline
- Knee Surgery - Arthroscopic and Open Procedures (CMM-312) Guideline
- Prolotherapy (CMM-204) Guideline
- Regional Sympathetic Blocks (CMM-209) Guideline
- Sacroiliac Joint Procedures (CMM-203) Guideline
- Shoulder Arthroplasty/Replacement/Resurfacing/Revision/Arthrodesis (CMM-318) Guideline
- Shoulder Surgery Arthroscopic and Open Procedures (CMM-315) Guideline
- Spinal Cord and Dorsal Root Ganglion Stimulation (CMM-211) Guideline
Spine Surgery
- Ablations/Denervations of Facet Joints and Peripheral Nerves (CMM-208) Guideline
- Anterior Cervical Discectomy and Fusion (CMM-601) Guideline
- Cervical Microdiscectomy (CMM-605) Guideline
- Cervical Total Disc Arthroplasty (CMM-602) Guideline
- Discography (CMM-401) Guideline
- Electrical and Low Frequency US Bone Growth Stimulation Spine (CMM-615) Guideline
- Grafts (CMM-612) Guideline
- Intradiscal Procedures (CMM-308) Guideline
- Lumbar Decompression (CMM-608) Guideline
- Lumbar Fusion (Arthrodesis) (CMM-609) Guideline
- Lumbar Microdiscectomy (Laminotomy, Laminectomy, or Hemilaminectomy) (CMM-606) Guideline
- Lumbar Total Disc Arthroplasty (CMM-610) Guideline
- Posterior Cervical Decompression (Laminectomy/ Hemilaminectomy/ Laminoplasty)(CMM-603) Guideline
- Posterior Cervical Fusion (CMM-604) Guideline
- Preface to Spine Surgery (CMM-600) Guideline
- Primary Vertebral Augmentation (Percutaneous Vertebroplasty-Kyphoplasty) and Sacroplasty (CMM-607) Guideline
- Sacroiliac Joint Fusion or Stabilization (CMM-611) Guideline
- Thoracic and Thoracolumbar Fusion (Arthrodesis) (CMM-614) Guideline
- Thoracic Decompression and Discectomy (CMM-613) Guideline
- Vertebral Body Tethering for Adolescent Idiopathic Scoliosis (CMM-616) Guideline
Gastrointestinal Endoscopic Procedure Guidelines
High-Tech Imaging and Cardiology Guidelines
- 2024 CPT 75580 Addendum to Cardiology & Radiology Imaging Guidelines
- Preface to the Imaging Guidelines
- Site of Care: High-tech Radiology
General
- Abdomen Imaging Guidelines
- Breast Imaging Guidelines - Effective 11/18/2025
- Breast Imaging Guidelines
- Cardiac Imaging Guidelines
- Chest Imaging Guidelines
- Head Imaging Guidelines
- Musculoskeletal Imaging Guidelines
- Neck Imaging Guidelines
- Oncology Imaging Guidelines - Effective 12/01/2025
- Oncology Imaging Guidelines
- Pacemaker (CID) Guidelines
- Pelvis Imaging Guidelines
- Peripheral Nerve and Neuromuscular Disorders (PNND) Imaging Guidelines
- Peripheral Vascular Disease (PVD) Imaging Guidelines
- Spine Imaging Guidelines
Pediatric
- Pediatric Abdomen Imaging Guidelines
- Pediatric and Special Populations Oncology Imaging Guidelines
- Pediatric and Special Populations Spine 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 and Neuromuscular Disorder (PNND) Imaging Guidelines
- Pediatric Peripheral Vascular Disease (PVD) Imaging Guidelines
Peripheral Vascular Intervention
Laboratory Management - Molecular
- Cigna Lab Management Guidelines
- Lab Management Prior Authorization CPT Code List - Effective 10/01/2025
- Lab Management Prior Authorization CPT Code List - Effective 11/01/2025
- Lab Management Prior Authorization CPT Code List
Administrative
- MOL.AD.107.A: Unique Test Identifiers for Non-Specific Procedure Codes
- MOL.AD.304.A: Medical Necessity Review Information Requirements
- MOL.AD.314.A: Date of Service and Authorization Period Effective Date
- MOL.AD.364.A: Special Circumstances Influencing Coverage Determinations
- MOL.AD.412.A: Laboratory Billing and Reimbursement
Clinical Use
- MOL.CU.109.A: Genetic Testing for Cancer Susceptibility and Hereditary Cancer Syndromes
- MOL.CU.110.A: Genetic Testing for Carrier Status
- MOL.CU.111.A: Genetic Testing for Non-Medical Purposes
- MOL.CU.112.A: Genetic Testing for Prenatal Screening and Diagnostic Testing
- MOL.CU.113.A: Genetic Testing for the Screening, Diagnosis, and Monitoring of Cancer
- MOL.CU.114.A: Genetic Testing to Diagnose Non-Cancer Conditions
- MOL.CU.115.A: Genetic Testing to Predict Disease Risk
- MOL.CU.116.A: Genetic Testing by Multigene Panels
- MOL.CU.117.A: Experimental, Investigational, or Unproven Laboratory Testing
- MOL.CU.118.A: Pharmacogenomic Testing for Drug Toxicity and Response
- MOL.CU.119.A: Preimplantation Genetic Screening and Diagnosis
- MOL.CU.246.A: Hereditary (Germline) Testing After Tumor (Somatic) Testing
- MOL.CU.256.A: Confirmatory Genetic Testing
- MOL.CU.291.A: Genetic Testing for Known Familial Mutations
- MOL.CU.292.A: Genetic Testing for Variants of Uncertain Clinical Significance
- MOL.CU.333.B: Medically Necessary Laboratory Testing
Test Specific
- MOL.TS.124.A: Alpha-1 Antitrypsin Deficiency Testing
- MOL.TS.125.A: Amyotrophic Lateral Sclerosis (ALS) Genetic Testing
- MOL.TS.126.A: Angelman Syndrome Genetic Testing
- MOL.TS.129.A: Ashkenazi Jewish Carrier Screening
- MOL.TS.130.A: Ataxia-Telangiectasia Genetic Testing
- MOL.TS.144.A: CADASIL Genetic Testing
- MOL.TS.148.A: Charcot-Marie-Tooth Neuropathy Genetic Testing
- MOL.TS.150.A: Chromosomal Microarray Testing For Developmental Disorders (Prenatal and Postnatal)
- MOL.TS.158.A: Cystic Fibrosis Genetic Testing
- MOL.TS.162.A: Early Onset Familial Alzheimer Disease Genetic Testing
- MOL.TS.165.C Carrier Screening Panels, Including Targeted, Pan-Ethnic, Universal, and Expanded
- MOL.TS.168.A: Familial Adenomatous Polyposis Genetic Testing
- MOL.TS.169.A: Familial Hypercholesterolemia Genetic Testing
- MOL.TS.170.A: Familial Malignant Melanoma Genetic Testing
- MOL.TS.182.A: Hereditary Cancer Syndrome Multigene Panels
- MOL.TS.183.A: HFE Hemochromatosis Genetic Testing
- MOL.TS.193.A: Li-Fraumeni Syndrome Genetic Testing
- MOL.TS.194.A: Liquid Biopsy Testing
- MOL.TS.197.A: Lynch Syndrome Genetic Testing
- MOL.TS.202.A: Marfan Syndrome Genetic Testing
- MOL.TS.206.A: MUTYH Associated Polyposis Genetic Testing
- MOL.TS.209.A: Non-Invasive Prenatal Screening
- MOL.TS.215.A: PCA3 Testing for Prostate Cancer
- MOL.TS.217.A: Prader-Willi Syndrome Genetic Testing
- MOL.TS.223.A: PTEN Hamartoma Tumor Syndromes Genetic Testing
- MOL.TS.225.A: Spinal Muscular Atrophy Genetic Testing
- MOL.TS.227.A: Thoracic Aortic Aneurysms and Dissections (TAAD) Panel Genetic Testing
- MOL.TS.228.A: Tissue of Origin Testing for Cancer of Unknown Primary
- MOL.TS.230.C: Somatic Mutation Testing
- MOL.TS.232.A: VeriStrat Testing for NSCLC TKI Response
- MOL.TS.235.C: Exome Sequencing
- MOL.TS.238.A: BRCA Analysis
- MOL.TS.248.A: Breast Cancer Index for Breast Cancer Prognosis
- MOL.TS.251.A: PALB2 Genetic Testing for Breast Cancer Risk
- MOL.TS.254.A: DecisionDX Uveal Melanoma
- MOL.TS.257.A: Epilepsy Genetic Testing
- MOL.TS.258.A: Maturity-Onset Diabetes of the Young (MODY) Genetic Testing
- MOL.TS.266.A: Mitochondrial Disorders Genetic Testing
- MOL.TS.267.A: Ehlers-Danlos Syndrome Genetic Testing
- MOL.TS.268.A: Hereditary Connective Tissue Disorder Genetic Testing
- MOL.TS.269.A: Autism, Intellectual Disability, and Developmental Delay Genetic Testing
- MOL.TS.271.A: PancraGEN
- MOL.TS.273.A: Nonsyndromic Hearing Loss and Deafness Genetic Testing
- MOL.TS.276.A: Polymerase Gamma (POLG) Related Disorders Genetic Testing
- MOL.TS.282.A: DermTech Pigmented Lesion Assay
- MOL.TS.287.A: Hereditary Pancreatitis Genetic Testing
- MOL.TS.288.A: Limb-Girdle Muscular Dystrophy Genetic Testing
- MOL.TS.290.A: Facioscapulohumeral Muscular Dystrophy Genetic Testing
- MOL.TS.294.A: Decipher Prostate Cancer Classifier
- MOL.TS.301.A: Neurofibromatosis Type 1 Genetic Testing
- MOL.TS.302.A: Legius Syndrome Genetic Testing
- MOL.TS.306.C: Genome Sequencing
- MOL.TS.307.A: AlloSure for Kidney Transplant Rejection
- MOL.TS.309.A: Friedreich Ataxia Genetic Testing
- MOL.TS.310.A: Hereditary Ataxia Multigene Panel Testing
- MOL.TS.311.A: Spinocerebellar Ataxia Genetic Testing
- MOL.TS.324.A: CHARGE Syndrome and CHD7 Disorder Genetic Testing (previously CHARGE Syndrome Genetic Testing)
- MOL.TS.344.A: Chromosomal Microarray for Solid Tumors
- MOL.TS.359.A: Inflammatory Bowel Disease Biomarker Testing
- MOL.TS.360.A: Inherited Bone Marrow Failure Syndrome (IBMFS) Testing
- MOL.TS.361.A: Human Platelet and Red Blood Cell Antigen Genotyping
- MOL.TS.371.A: Noonan Spectrum Disorder Genetic Testing
- MOL.TS.396.A: Multi-Cancer Early Detection Screening
- MOL.TS.410.A: Cardiomyopathy and Arrhythmia Genetic Testing
- MOL.TS.419.A: Primary Ciliary Dyskinesia Genetic Testing
Radiation & Medical Oncology Guidelines
Medical Oncology
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 Cancer Physician Worksheet
- Non-Cancerous Diagnosis Physician Worksheet
- Non-Hodgkin's Lymphoma Physician Worksheet
- Non-Small Cell Lung Cancer Physician Worksheet
- Other Cancer Type 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
Sleep Clinical 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
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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