Preface to the Comprehensive Musculoskeletal Management (CMM) Guidelines
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Preface and administrative instructions for applying the Cigna/EviCore Comprehensive Musculoskeletal Management (CMM) Guidelines to prior authorization and coverage determinations for musculoskeletal services; intended for providers and medical reviewers administering Cigna health benefit plans.
No material clinical or coverage changes in this revision.
Coverage Criteria and Coding Rules
General Prior Authorization and Medical Necessity Criteria
Covered when documentation demonstrates medical necessity as determined by the applicable benefit plan and guideline elements
Required for prior authorization
Needed to process sequential/similar requests
May require plan-specific handling
Administrative Coverage Conditions
Coverage and applicability are subject to the following administrative conditions:
Providers should obtain written plan-specific instructions.
Refer to CMS CED list for currently approved procedures.
See Guidelines Definitions for EIU handling.
Coding and Medical Necessity Criteria
Covered when coding and documentation accurately reflect the planned procedures and support medical necessity:
Authorization requests must use the codes that most accurately reflect planned procedures.
Anatomic or procedural incompatibility defines mutual exclusivity.
Insufficient support for units/levels may render codes not medically necessary.
Authorization of add-on codes follows the decision for the primary procedure.
Component codes requested in addition to a comprehensive code are not authorized unless clinically justified and performed separately.
For beneficiaries enrolled in Medicare or Medicare Advantage plans, CMS coverage policies supersede the CMM Guidelines. Providers should follow applicable CMS determinations for Medicare enrollees and obtain plan-specific written instructions when coverage differs from the CMM Preface.
Procedures or services identified as experimental, investigational, or unproven (EIU) are governed by the separate Guidelines Definitions document. Such services may be excluded from coverage per the applicable benefit plan; providers should reference the Definitions document for the CMM handling of EIU procedures and consult plan policy as needed.
When requesting add-on codes, the add-on must be associated with an allowed primary procedure code; add-on codes cannot be billed or authorized independently. An add-on requested without its related primary code, or when the primary procedure is not medically necessary, will be considered not medically necessary. Component procedure codes that are integral to a more comprehensive code should not be submitted separately unless performed independently during a separate encounter.
If a Category III or other specific temporary code accurately represents the service, it should be used in place of an unlisted code. Guidance for use and management of unlisted codes is provided in the Management of Unlisted Codes document and should be followed when an exact CPT code is not available.
Requests that include mutually exclusive codes, improper code combinations, codes that do not reflect the planned procedure, or unsupported quantities/levels risk being determined not medically necessary. Examples include: requesting two surgical technique codes that cannot reasonably be performed together, submitting a code limited to one unit multiple times without support, using component codes instead of a single comprehensive code, or failing to document intra‑operative changes that alter coding.
Codes will be considered not medically necessary when they are mutually exclusive with another requested code for the same date of service, when requested units or levels are not supported by the medical information, when add-on codes are submitted without an appropriate primary code, or when component procedure codes are used in place of a single more comprehensive code.
Coding Guidance and Code Lists
| CPT | Reference to CPT® codes and copyright; specific CPT codes are not listed in this preface. |
| Category III CPT | Category III CPT codes are temporary codes used to reflect emerging technologies, procedures, or services; use in place of an unlisted code when the Category III code accurately reflects the service performed. |
| Unlisted codes | See the Management of Unlisted Codes document for guidance on use of unlisted codes. |
| Improper/Mutually Exclusive/Quantity Rules | Coding rules describing improper coding (codes that do not accurately reflect the planned procedure, omitted required additional codes, obsolete codes, or codes limited to one unit), mutually exclusive codes (codes that cannot reasonably be performed together), and quantity/level limits (number of units or levels must be supported by medical information) that affect medical necessity determinations. |
| + (add-on indicator) | Add-on codes are identified by a '+' in CPT and must be associated with an allowed primary procedure code; add-on codes cannot be reported alone and are authorized only when the primary procedure is allowed. |
Provider Requirements, Documentation, and Denial Risks
Submit complete evaluation and records for prior authorization
Prior authorization requires submission of the complete evaluation and supporting records described in the documentation section; exceptions to guideline requirements require medical record submission to justify the exception. Without these records, medical necessity cannot be established.
- Include recent consultation, detailed history, physical exam findings, prior and current treatment response, and diagnostic testing.
- Advanced imaging must include an independent radiologist interpretation and any significant discrepant interpretations must be reconciled in the prior authorization documentation.
Select the most accurate CPT/HCPCS code (use Category III when applicable)
Use the HCPCS/CPT code(s) that most accurately reflect the planned procedure(s) or service(s) as typically performed for utilization management requests; when a Category III CPT code accurately reflects the service, it should be used instead of an unlisted code.
- Request the code(s) per AMA CPT guidance; Category III codes replace unlisted codes when accurate.
- See Management of Unlisted Codes guidance if no Category III or specific CPT code applies.
Ensure accurate CPT/HCPCS coding on authorization requests
Authorization requests must use the HCPCS/CPT codes that most accurately reflect the planned procedure(s) as typically performed; requests that misrepresent units/levels, add-on relationships, or unbundle a comprehensive code risk denial.
- Document any intra-operative discoveries and coding changes in the medical record to support submitted codes.
- Do not request codes that are explicitly limited to one unit more than once.
Follow policy text for coding and documentation when no label provided
If no specific summary label is provided, follow the policy text for coding and documentation requirements and submit the required medical records to support the request.
- Requests must include documentation described in the documentation section to establish medical necessity.
- Coding must reflect the planned procedure as typically performed per AMA CPT guidance.
Confirm plan and legislative precedence before submission
Coverage determinations may be affected by the enrollee's health plan benefits and state or federal legislative mandates; obtain written, plan-specific instructions and requirements prior to submission.
- For Medicare and Medicare Advantage enrollees, CMS coverage policies supersede these guidelines.
- Providers are urged to obtain written instructions directly from each payor.
When label missing, provide full documentation and follow unlisted-code guidance
If no specific summary label is provided, submit full clinical documentation and coding that accurately reflect the planned procedure and follow the Management of Unlisted Codes when applicable.
- Provide the complete evaluation and supporting records described in the documentation section.
- Use Category III CPT codes in place of unlisted codes when they accurately reflect the service.
Perform and document a complete pre-procedure evaluation
Prior to any procedure or service, perform a complete evaluation and include in the prior authorization submission: recent consultation, detailed history, relevant physical exam findings, prior/current treatment response, and diagnostic testing (e.g., ultrasound, x‑ray, CT, MRI, myelography).
- Advanced imaging must include interpretation by an independent radiologist; reconcile any clinically significant interpretation discrepancies in the submitted documentation.
- Include reports from other treating providers or specialists.
Provide prior-procedure outcome or nonperformance documentation for sequential requests
For sequential or similar/duplicate requests, include documentation showing the effect of the prior authorized procedure/service or, if a prior authorized procedure was not performed, documentation of nonperformance.
- Document outcomes of prior authorized procedures when part of ongoing treatment.
- If a prior authorization was granted but the procedure was not performed, provide documentation explaining nonperformance.
Request and document accurate CPT/HCPCS codes
Request CPT/HCPCS codes that most accurately reflect the planned procedure(s) or service(s) as typically performed and include documentation of any intra‑operative discoveries or coding changes in the medical record to support the submitted codes.
- If code combinations are changed due to intra-operative findings, document those changes and the supporting medical information.
- Do not submit codes that are obsolete or that can be replaced with a more accurate single code without justification.
Support requested number of units or levels with medical records
Medical information submitted must support the number of units or levels requested; codes limited to one unit should not be requested more than once and unsupported unit/level requests may be considered not medically necessary.
- Provide objective documentation that justifies multiple units or additional levels.
- If a code is explicitly limited to one unit, do not request multiple units for that code.
Associate add-on codes with an allowed primary procedure
Add-on codes must be associated with an allowed primary procedure code; authorization of add-on codes follows the decision for the primary procedure and add-ons requested without an allowed primary will be considered not medically necessary.
- Identify the primary procedure code to which add-on codes will be linked.
- If the primary code is not authorized, associated add-on codes will not be authorized.
Document justification for mutually exclusive or component code combinations
When codes are mutually exclusive or represent component procedures of a more comprehensive code, include documentation that justifies why both codes are necessary (for example, separate encounter or anatomically distinct procedures).
- Explain why procedures could not reasonably be performed together if claiming both codes for the same date of service.
- If component procedures were performed as independent, separate encounters, document accordingly so they can be reviewed individually.
Missing required documentation may result in denial
Requests outside guideline requirements that do not include medical records documenting the individual's current clinical status and justification for an exception cannot have medical necessity established and therefore risk denial.
- Always submit medical records when requesting exceptions to policy.
- Lack of this information may result in denial because medical necessity cannot be determined.
Mutually exclusive code combinations risk denial
Requests using mutually exclusive HCPCS/CPT codes for the same date of service where one code does not most accurately reflect the procedure are considered not medically necessary and may be denied.
- The code that does not most accurately reflect the procedure will be considered not medically necessary.
- Examples include two different surgical techniques at the same anatomical location on the same date.
Unsupported units/levels may lead to denial
Requests where the number of units or levels is not supported by medical information, or when a code is explicitly limited to one unit, are considered not medically necessary and may be denied.
- Provide documentation to justify multiple units or levels; unsupported requests may be denied.
- Do not request more than one unit for codes explicitly limited to one unit.
Improper or inaccurate coding may trigger denial
When submitted code(s) do not accurately represent the planned procedure or omit required additional codes, the request may be denied for improper coding.
- Document intra-operative changes and include any additional codes required to represent the procedure.
- Avoid submitting obsolete codes or code combinations that should be replaced by a single, more accurate code.
Mutually exclusive codes may be removed or denied
If codes requested are mutually exclusive for the same date of service, the code that does not most accurately reflect the procedure as typically performed may be removed or denied.
- Mutually exclusive codes cannot reasonably be performed at the same time due to anatomy or procedure nature.
- The less accurate code will be considered not medically necessary.
Unsupported quantity/levels are denial risks
Requests with a number of units or levels not supported by the medical information, or when a code is limited to one unit, may be considered not medically necessary and denied.
- Ensure documentation specifically supports the requested number of units/levels.
- Codes explicitly limited to one unit should not be requested multiple times.
Add-on codes without an authorized primary risk denial
Add-on codes requested without an allowed primary code, or when the associated primary procedure is not medically necessary, will be considered not medically necessary and can be denied.
- Do not submit add-on codes alone; include the authorized primary procedure code.
- If the primary procedure is denied, associated add-on codes will also be considered not medically necessary.
Unbundling (using component codes instead of a comprehensive code) risks denial
When multiple procedure codes are used instead of a single more comprehensive code (unbundling), the component codes may be considered not medically necessary and denied.
- Request the single comprehensive code when it more accurately represents the performed procedure.
- Component procedure codes may be authorized only if performed independently during a separate encounter and documented as such.
Background and Scope
The CMM Guidelines are intended as evidence‑based coverage guidance to assist in medical necessity determinations for musculoskeletal procedures under Cigna‑administered plans. They do not replace the applicable benefit plan document or legal requirements; coverage decisions remain governed by the individual health plan and relevant laws. The preface frames these Guidelines as tools for prior authorization and utilization management, emphasizing that documentation must demonstrate medical necessity and that plan‑specific or CMS policies may take precedence.
Definitions and Key Terms
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