Cardiology, Musculoskeletal and Advanced Imaging Services Prior Authorization List of Services
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Defines which cardiology, musculoskeletal/orthopedic and advanced imaging services require prior authorization through Cohere Health (and sometimes HealthPartners) for specified HealthPartners plans; intended for providers and administrative staff submitting authorizations.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization
Prior authorization requirement
Covered when ALL of the following are met:
Cohere criteria and CMS NCD/LCDs govern medical necessity determinations; providers must consult those sources.
This document is a payer-maintained list of services and procedure codes that may require prior authorization. It is intended to inform providers and administrative staff which Cardiology, Musculoskeletal/Orthopedic, and Advanced Imaging services are subject to authorization processes. Listing of a service or code in this document does not guarantee coverage or payment; coverage is determined by the member’s specific HealthPartners plan documents. If the plan documents conflict with the information here, the plan documents will govern.
This list identifies services that may require prior authorization but does not itself define clinical medical necessity rules. Medical necessity and coverage for Medicare Advantage members are determined by CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), other published CMS guidance, or Cohere Medicare Advantage Guidelines when CMS guidance is absent. For non‑Medicare plans, providers must follow the authorization criteria and documentation requirements specified by Cohere Health and the member’s plan documents.
Code Groups by Service Type
What Providers Must Do
Prior authorization required through Cohere Health for listed services
Prior authorization is required through Cohere Health for the listed cardiology, musculoskeletal, and advanced imaging procedure codes when the member is covered under the specified HealthPartners plans (Fully Insured Commercial; Self-Insured Level Funded Commercial; Minnesota Health Care Programs — PMAP, MSC+, MSHO; and Medicare Advantage). Codes are listed in the policy and require submission to Cohere for authorization prior to service as indicated by the plan.
- Applies to the code groups listed in the policy (CT/CTA, MRA/MRI/MRCP, PET, cardiac ablation and implantable devices, vascular interventional procedures, cardiac catheterization/TAVR, large-joint arthroplasty, spine and pain procedures).
- Prior authorization through HealthPartners may still be required for other self‑insured plans; refer to plan documents.
Use Cohere Health process and criteria for authorization requests
Cohere Health is the utilization management vendor identified by HealthPartners to handle authorizations for these services; providers must use Cohere's processes and portals to request authorization for the listed procedures.
- Cohere's specific criteria may be accessed at Cohere Guidelines All Specialties - Payer Information.
- For services and plans that require authorization through Cohere, refer to the policy table of codes.
Provide documentation per plan documents and Cohere Guidelines
Providers must refer to the member's plan documents and to Cohere Guidelines (and CMS NCDs/LCDs or other CMS guidance for Medicare Advantage) for the specific authorization criteria and the supporting documentation required when submitting an authorization request.
- If CMS guidance is absent or not fully established for Medicare Advantage, Cohere Medicare Advantage Guidelines apply.
- Plan documents govern coverage if there is any difference between this list and plan-specific information.
Risk of claim denial or nonpayment if authorization is not obtained
Failure to obtain prior authorization through Cohere for listed services when required by the member's HealthPartners plan may result in denial or lack of coverage/payment for the service.
- Codes listed are informational and do not guarantee coverage or reimbursement; lack of authorization can place claims at risk.
- Contact Member Services for Medicare coverage questions (952-883-7272 or 1-877-778-8384).
Policy Background
Background: This document functions as an authorization list and code reference rather than a medical policy that states detailed clinical criteria. HealthPartners uses Cohere Health for utilization management of select services; providers should consult Cohere Guidelines and applicable CMS guidance for the specific clinical criteria, required documentation, and decision logic used in authorization determinations. Contact Member Services for Medicare coverage policy copies or questions.
Key Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.