Cigna Medicare Advantage Membership
Clinical Guidelines.

Durable Medical Equipment Guidelines

• 
  Clinical Info for Medical Necessity
• 
  DME.AD.104.A Medicare: Hierarchy for Applying Coverage Decisions
• 
  Durable Medical Equipment (DME) Clinical Guidelines for Medical Necessity
• 
  eviCore Durable Medical Equipment (DME) Guidelines

Hi Tech Imaging and Cardiology Guidelines

• 
  Clinical Info for Medical Necessity Policy
• 
  Clinical Info for Medical Necessity Policy - Effective 04/01/2023
• 
  Site of Care: High-tech Radiology

General

• 
  Preface to the Guidelines
• 
  Preface to the Guidelines - Effective 04/01/2023
• 
  Abdomen Imaging Guidelines
• 
  Abdomen Imaging Guidelines - Effective 04/01/2023
• 
  Breast Imaging Guidelines
• 
  Breast Imaging Guidelines - Effective 04/01/2023
• 
  Cardiac Imaging Guidelines - Effective 04/01/2023
• 
  Cardiac Imaging Guidelines
• 
  Chest Imaging Guidelines
• 
  Chest Imaging Guidelines - Effective 04/01/2023
• 
  Head Imaging Guidelines
• 
  Head Imaging Guidelines - Effective 04/01/2023
• 
  Musculoskeletal Imaging Guidelines
• 
  Musculoskeletal Imaging Guidelines - Effective 04/01/2023
• 
  Neck Imaging Guidelines
• 
  Neck Imaging Guidelines
• 
  Neck Imaging Guidelines - Effective 04/01/2023
• 
  Oncology Imaging Guidelines
• 
  Oncology Imaging Guidelines - Effective 04/01/2023
• 
  Pacemaker (CID) Guidelines
• 
  Pacemaker (CID) Guidelines - Effective 04/01/2023
• 
  Pelvis Imaging Guidelines
• 
  Pelvis Imaging Guidelines - Effective 04/01/2023
• 
  Peripheral Nerve Disorders (PND) Imaging Guidelines
• 
  Peripheral Nerve Disorders (PND) Imaging Guidelines - Effective 04/01/2023
• 
  Peripheral Vascular Disease (PVD) Imaging Guidelines
• 
  Peripheral Vascular Disease (PVD) Imaging Guidelines - Effective 04/01/2023
• 
  Spine Imaging Guidelines
• 
  Spine Imaging Guidelines - Effective 04/01/2023

Pediatric

• 
  Pediatric Abdomen Imaging Guidelines
• 
  Pediatric Abdomen Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Cardiac Imaging Guidelines
• 
  Pediatric Cardiac Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Chest Imaging Guidelines
• 
  Pediatric Chest Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Head Imaging Guidelines
• 
  Pediatric Head Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Musculoskeletal Imaging Guidelines
• 
  Pediatric Musculoskeletal Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Neck Imaging Guidelines
• 
  Pediatric Neck Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Oncology Imaging Guidelines
• 
  Pediatric Oncology Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Pelvis Imaging Guidelines
• 
  Pediatric Pelvis Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Peripheral Nerve Disorders (PND) Imaging Guidelines
• 
  Pediatric Peripheral Nerve Disorders (PND) Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Peripheral Vascular Disease (PVD) Imaging Guidelines
• 
  Pediatric Peripheral Vascular Disease (PVD) Imaging Guidelines - Effective 04/01/2023
• 
  Pediatric Spine Imaging Guidelines
• 
  Pediatric Spine Imaging Guidelines - Effective 04/01/2023

Post Acute Care Guidelines

• 
  Clinical Info for Medical Necessity
• 
  Post-Acute Care Guidelines
• 
  Supplementary Home Health Guidelines

Radiation and Medical Oncology Guidelines

Medical Oncology

• 
  Oncology Medications Policy
• 
  Oncology Medications Policy - Effective 04/01/2023

Radiation Oncology

• 
  Radiation Oncology Clinical Appeal Documentation Requirements
• 
  Radiation Oncology Coding Manual
• 
  Radiation Oncology Clinical Guidelines

Physician Worksheets

• 
  Adrenal Cancer Physician Worksheet
• 
  Anal Canal Cancer Physician Worksheet
• 
  Bile Duct Cancer Physician Worksheet
• 
  Bladder Cancer Physician Worksheet
• 
  Bone Metastases Physician Worksheet
• 
  Bone Metastases - Xofigo Physician Worksheet
• 
  Brain Metastases Physician Worksheet
• 
  Breast Cancer CDS Online Document
• 
  Central Nervous System Lymphoma Physician Worksheet
• 
  Central Nervous System Neoplasm Physician Worksheet
• 
  Cervical Cancer Physician Worksheet
• 
  Endometrial Cancer Physician Worksheet
• 
  Esophagus 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
• 
  Hodgkins 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 Radiation Therapy Physician Worksheet
• 
  Non-Hodgkins Lymphoma Physician Worksheet
• 
  Non-Small Cell Lung Cancer CDS Online Document
• 
  Other Cancer Type Physician Worksheet
• 
  Other Metastases (Non-Bone/Brain) Physician Worksheet
• 
  Pancreatic Cancer Physician Worksheet
• 
  Prophylactic Cranial Irradiation (PCI) Physician Worksheet
• 
  Prostate Cancer CDS Online Document
• 
  Radiopharmaceuticals Physician Worksheet
• 
  Rectal Cancer Physician Worksheet
• 
  Skin Cancer CDS Online Document
• 
  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
• 
  Site of Care: Outpatient Hospital for Select Musculoskeletal Procedures
• 
  Preface to Comprehensive Musculoskeletal Management Guidelines
• 
  Epidural Adhesiolysis (CMM-207) Guideline
• 
  Epidural Adhesiolysis (CMM-207) Guideline - Effective 05/31/2023
• 
  Epidural Steroid Injections (CMM-200) Guideline
• 
  Epidural Steroid Injections (CMM-200) Guideline - Effective 05/31/2023
• 
  Facet Joint Injections / Medial Branch Blocks (CMM-201) Guideline
• 
  Facet Joint Injections / Medial Branch Blocks (CMM-201) Guideline - Effective 05/31/2023
• 
  Hip Replacement/Arthroplasty (CMM-313) Guideline - Effective 05/31/2023
• 
  Hip Replacement/Arthroplasty (CMM-313) Guideline
• 
  Hip Surgery Arthroscopic and Open Procedures (CMM-314) Guideline
• 
  Hip Surgery Arthroscopic and Open Procedures (CMM-314) Guideline - Effective 05/31/2023
• 
  Implantable Intrathecal Drug Delivery System (CMM-210) Guideline
• 
  Implantable Intrathecal Drug Delivery System (CMM-210) Guideline - Effective 05/31/2023
• 
  Knee Replacement Arthroplasty (CMM-311) Guideline - Effective 05/31/2023
• 
  Knee Replacement Arthroplasty (CMM-311) Guideline
• 
  Knee Surgery: Arthroscopic and Open Procedures (CMM-312) Guideline - Effective 05/31/2023
• 
  Knee Surgery: Arthroscopic and Open Procedures (CMM-312) Guideline
• 
  Prolotherapy (CMM-204) Guideline
• 
  Prolotherapy (CMM-204) Guideline - Effective 05/31/2023
• 
  Radiofrequency Joint Ablations/Denervations (CMM-208) Guideline - Effective 05/31/2023
• 
  Radiofrequency Joint Ablations/Denervations (CMM-208) Guideline
• 
  Regional Sympathetic Blocks (CMM-209) Guideline
• 
  Regional Sympathetic Blocks (CMM-209) Guideline - Effective 05/31/2023
• 
  Sacroiliac Joint Procedures (CMM-203) Guideline
• 
  Sacroiliac Joint Procedures (CMM-203) Guideline - Effective 05/31/2023
• 
  Shoulder Surgery (CMM 315) Arthroscopic and Open Procedures Guideline - Effective 05/31/2023
• 
  Shoulder Surgery (CMM 315) Arthroscopic and Open Procedures Guideline
• 
  Shoulder Arthroplasty/ Arthrodesis (CMM-318) Guideline - Effective 05/31/2023
• 
  Shoulder Arthroplasty/ Arthrodesis (CMM-318) Guideline
• 
  Spinal Cord and Dorsal Root Ganglion Stimulation (CMM-211) Guideline
• 
  Spinal Cord and Dorsal Root Ganglion Stimulation (CMM-211) Guideline - Effective 05/31/2023