Cardiology, Musculoskeletal and Advanced Imaging Services Prior Authorization List
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Lists services and CPT/HCPCS codes that require prior authorization through Cohere Health for specified HealthPartners plans and provides guidance on Medicare coverage references for cardiology, musculoskeletal, and advanced imaging procedures.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
Authorization requirement
Covered when prior authorization is obtained through Cohere Health and the member is enrolled in one of the specified HealthPartners plans.
Cohere-specific clinical criteria apply and must be consulted for each service (access via Cohere Guidelines).
Services listed in this document require prior authorization through Cohere Health for the specified HealthPartners plans. Note that prior authorization through HealthPartners may still be required for other self‑insured plans; providers must consult the member's plan documents to determine coverage for any given benefit. For questions about Medicare coverage criteria or to request a copy of a Medicare coverage policy, contact Member Services at the numbers listed in the plan materials.
Procedure and Device Codes Requiring Prior Authorization
| 73725 | MRA code listed |
| 74185 | MRA code listed |
| C8900 | MRA HCPCS/implant code listed |
| C8901 | MRA HCPCS/implant code listed |
| C8902 | MRA HCPCS/implant code listed |
| C8909 | MRA HCPCS/implant code listed |
| C8910 | MRA HCPCS/implant code listed |
| C8911 | MRA HCPCS/implant code listed |
| C8912 | MRA HCPCS/implant code listed |
| C8913 | MRA HCPCS/implant code listed |
| 33240 | Cardiac implantable device |
| 33241 | Cardiac implantable device |
| 33244 | Cardiac implantable device |
| 33249 | Cardiac implantable device |
| 33262 | Cardiac implantable device |
| 33263 | Cardiac implantable device |
| 33264 | Cardiac implantable device |
| 33270 | Cardiac implantable device |
| 33271 | Cardiac implantable device |
| 33272 | Cardiac implantable device |
| 93453 | Left and right cardiac catheterization |
| 93456 | Left and right cardiac catheterization |
| 93457 | Left and right cardiac catheterization |
| 93460 | Left and right cardiac catheterization |
| 93461 | Left and right cardiac catheterization |
| 93596 | Left and right cardiac catheterization |
| 93597 | Left and right cardiac catheterization |
| 27870 | Ankle arthrodesis |
| 27700 | Ankle arthroplasty |
| 27702 | Ankle arthroplasty |
| 28110 | Bunionette surgical treatment |
| 28308 | Bunionette surgical treatment |
| 22859 | Cervical spinal fusion |
| 22899 | Unlisted spine code |
| 62320 | Epidural steroid injection |
| 62321 | Epidural steroid injection |
| 62322 | Epidural steroid injection |
| 63650 | Spinal cord stimulator implantation |
| 63655 | Spinal cord stimulator |
| 63663 | Spinal cord stimulator |
| 63664 | Spinal cord stimulator |
| 63685 | Spinal cord stimulator |
| 63688 | Spinal cord stimulator |
| C1816 | Spinal cord stimulator device HCPCS |
| C1820 | Spinal cord stimulator device HCPCS |
| C1822 | Spinal cord stimulator device HCPCS |
| L8679 | Spinal cord stimulator lead |
| 0707T | Subchondroplasty |
| 0656T | Vertebral body tethering |
| 0657T | Vertebral body tethering |
| 22856 | Total disc arthroplasty |
| 22857 | Total disc arthroplasty |
| 22858 | Total disc arthroplasty |
| 22861 | Total disc arthroplasty |
| 22862 | Total disc arthroplasty |
| 0095T | Total disc arthroplasty |
| 0098T | Total disc arthroplasty |
Provider Actions and Authorization Process
Imaging prior authorization
The listed CT, CTA, MRA, MRI, MRCP, and PET procedure codes require prior authorization through Cohere Health for the specified HealthPartners plans. Providers must obtain authorization through Cohere Health before performing these services for members of Self-Insured Level Funded Commercial, Fully Insured Commercial, Minnesota Health Care Programs (PMAP, MSC+, MSHO), and Medicare Advantage plans offered by HealthPartners.
- Affected CPT/HCPCS codes include CT: 70491, 70492, 71250, 71260, 71270, 72125–72129, 74176–74178, 74261–74262; CTA: 70496, 70498, 71275, 73706, 75635; MRA: 73725, 74185 and listed C-codes; MRI (extremity/spine/etc.): 73718–73723, 77084; PET: 78608–78609, 78812–78816, G0219, G0235, G0252.
- Prior authorization is obtained via Cohere Health — follow Cohere's submission and documentation requirements.
Providers should note this requirement affects scheduling and billing workflows; confirm authorization prior to service to avoid claim denials or member liability.
Where to find criteria and Medicare guidance
Providers should refer to Cohere Guidelines (Cohere Health) for the specific utilization management criteria that govern these authorizations. For Medicare coverage rules that determine applicability to Medicare Advantage plans, refer to CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), the Medicare Benefit Manual, and MLN Matters publications. For assistance or a copy of a Medicare coverage policy, contact HealthPartners Member Services at 952-883-7272 or 1-877-778-8384.
- Cohere Guidelines — AII Specialties Payer Information (access via Cohere Health portal)
- CMS NCDs, LCDs, Medicare Benefit Manual, MLN Matters
Prior authorization required
Failure to obtain prior authorization through Cohere Health for the listed services may result in denial of coverage or member financial responsibility. Prior authorization requirements listed here apply to the HealthPartners plans identified; other self‑insured employer plans may have additional HealthPartners authorization requirements—verify plan-specific rules.
- Contact Member Services for plan-specific coverage or to request Medicare policy copies: 952-883-7272 or 1-877-778-8384.
Policy Background
This prior authorization list groups cardiology, musculoskeletal, and advanced imaging services by procedure type and enumerates the CPT/HCPCS codes that require prior authorization through Cohere Health for certain HealthPartners plans. HealthPartners uses Cohere Health to provide utilization management for these selected services; Cohere's specific clinical criteria should be consulted (Cohere Guidelines) when submitting authorization requests. The document also notes that Medicare Advantage coverage follows applicable NCDs/LCDs and other CMS guidance, and that Member Services can be contacted for Medicare coverage policy information.
Definitions
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