Cigna Commercial Membership Clinical 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  Additional clinical guidelines may be developed as needed or may be withdrawn from use.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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