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Cigna Commercial Membership Clinical Guidelines
For Cigna Medicare membership guidelines click here.
Supplemental Information
Comprehensive Musculoskeletal Management Guidelines
- Ablations/Denervations of Facet Joints and Peripheral Nerves (CMM-208) Guideline - Effective 11/01/2024
- Clinical Information to Establish Medical Necessity
- CMM-401 Discography - Effective 11/01/2024
- CMM-600 Preface to Spine Surgery - Effective 11/01/2024
- CMM-601 Anterior Cervical Discectomy and Fusion - Effective 11/01/2024
- CMM-602 Cervical Total Discectomy Arthroplasty - Effective 11/01/2024
- CMM-603: Posterior Cervical Decompression - Effective 11/01/2024
- CMM-604 Posterior Cervical Fusion Guidelines - Effective 11/01/2024
- CMM-605 Cervical Microdiscectomy - Effective 11/01/2024
- CMM-606 Lumbar Microdiscectomy - Effective 11/01/2024
- CMM-607 Primal Vertebral Augmentation (Percutaneous Vertebroplasty-Kyphoplasty) and Sacroplasty - Effective 11/01/2024
- CMM-608 Lumbar Decompression - Effective 11/01/2024
- CMM-609 Lumbar Fusion (Arthrodesis) - Effective 11/01/2024
- CMM-610 Lumbar Total Discectomy Arthroplasty - Effective 11/01/2024
- CMM-611 Sacroiliac Joint Fusion or Stabilization - Effective 11/01/2024
- CMM-612 Grafts - Effective 11/01/2024
- CMM-613 Thoracic Decompression and Discectomy - Effective 11/01/2024
- CMM-614 Thoracic and Thoracolumbar Fusion (Arthrodesis) - Effective 11/01/2024
- CMM-615 Electrical and Low Frequency US Bone Growth Stimulation Spine - Effective 11/01/2024
- CMM-616 Vertebral Body Tethering for Adolescent Idiopathic Scoliosis - Effective 11/01/2024
- Discography (CMM-401) Guideline - Effective 11/01/2024
- Epidural Adhesiolysis (CMM-207) Guideline
- Epidural Adhesiolysis (CMM-207) Guideline - Effective 08/01/2024
- Epidural Steroid Injections (CMM-200) Guideline - Effective 08/01/2024
- Epidural Steroid Injections (CMM-200) Guideline
- Facet Joint Injections/Medial Branch Blocks (CMM-201) Guideline
- Facet Joint Injections/Medial Branch Blocks (CMM-201) Guideline - Effective 08/01/2024
- Hip Replacement/Arthroplasty (CMM-313) Guideline
- Hip Replacement/Arthroplasty (CMM-313) Guideline - Effective 08/01/2024
- Hip Surgery Arthroscopic and Open Procedures (CMM-314) Guideline
- Hip Surgery Arthroscopic and Open Procedures (CMM-314) Guideline - Effective 08/01/2024
- Implantable Intrathecal Drug Delivery System (CMM-210) Guideline
- Implantable Intrathecal Drug Delivery System (CMM-210) Guideline - Effective 08/01/2024
- Interventional Pain Management Quick Reference Guide Guideline
- Joint Surgery Quick Reference Guide Guideline
- Knee Replacement Arthroplasty (CMM-311) Guideline - Effective 08/01/2024
- Knee Replacement Arthroplasty (CMM-311) Guideline
- Knee Surgery: Arthroscopic and Open Procedures (CMM-312) Guideline
- Knee Surgery: Arthroscopic and Open Procedures (CMM-312) Guideline - Effective 08/01/2024
- Preface to the Comprehensive Musculoskeletal Guidelines
- Preface to the Comprehensive Musculoskeletal Guidelines - Effective 08/01/2024
- Preface to the Comprehensive Musculoskeletal Guidelines - Effective 11/01/2024
- Prolotherapy (CMM-204) Guideline - Effective 08/01/2024
- Prolotherapy (CMM-204) Guideline
- Radiofrequency Joint Ablations/Denervations (CMM-208) Guideline - Effective 08/01/2024
- Radiofrequency Joint Ablations/Denervations (CMM-208) Guideline
- Regional Sympathetic Blocks (CMM-209) Guideline
- Regional Sympathetic Blocks (CMM-209) Guideline - Effective 08/01/2024
- Sacroiliac Joint Procedures (CMM-203) Guideline
- Sacroiliac Joint Procedures (CMM-203) Guideline - Effective 08/01/2024
- Shoulder Arthroplasty/ Arthrodesis (CMM-318) Guideline
- Shoulder Arthroplasty/Arthrodesis (CMM-318) Guideline - Effective 08/01/2024
- Shoulder Surgery (CMM 315) Arthroscopic and Open Procedures Guideline
- Shoulder Surgery (CMM 315) Arthroscopic and Open Procedures Guideline - Effective 08/01/2024
- Spinal Cord and Dorsal Root Ganglion Stimulation (CMM-211) Guideline
Gastrointestinal Endoscopic Procedure Guidelines
High-Tech Imaging and Cardiology Guidelines
- 2024 CPT 75580 Addendum to Cardiology & Radiology Imaging 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 - Effective 10/15/2024
- Cardiac Imaging Guidelines
- Chest Imaging Guidelines
- Head Imaging Guidelines
- Musculoskeletal Imaging Guidelines
- Neck Imaging Guidelines
- Oncology Imaging Guidelines - Effective 08/01/2024
- Oncology Imaging Guidelines
- Pacemaker (CID) Guidelines
- Pelvis Imaging Guidelines
- Peripheral Nerve Disease (PND) Imaging Guidelines
- Peripheral Vascular Disease (PVD) Imaging Guidelines
- Spine Imaging Guidelines
- Spine Imaging Guidelines - Effective 08/01/2024
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
Peripheral Vascular Intervention
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 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
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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