Evicore Coverage Criteria
Latest Evicore coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Spine Imaging Guidelines — Advanced Diagnostic Imaging Coverage (MRI/CT/MRA/Ultrasound)Rules and clinical criteria governing when advanced spine imaging (MRI, CT, MRA, MR spectroscopy, ultrasound) is medically necessary for Cigna plans managed by eviCore; applies to cervical, thoracic, lumbar spine and pelvis regions.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Ablations/Denervations of Facet Joints and Peripheral NervesDefines medical necessity, procedural limits, imaging and guidance requirements, and indications for radiofrequency denervation/ablation of facet joints and select peripheral nerve destruction for Cigna-administered plans.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Anterior Cervical Discectomy and FusionDefines medical necessity criteria and procedural requirements for initial and repeat anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy with fusion, and related indications (radiculopathy, myelopathy, pseudoarthrosis, implant failure) for Cigna members; intended for providers requesting authorization or performing surgery.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Cervical MicrodiscectomyMedical necessity and coverage guidance for initial and repeat cervical microdiscectomy procedures for patients with radiculopathy or myelopathy under Cigna-administered plans reviewed by eviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Cervical Total Disc ArthroplastyThis policy governs medical necessity criteria, general guidelines, and indications for cervical total disc arthroplasty (CTDA) for Cigna-administered health benefit plans and describes review pathways for initial, failed, and adjacent-segment scenarios.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04DiscographyCoverage policy for discography procedures (diagnostic injection of contrast into intervertebral discs) as applied to health benefit plans administered by Cigna and used by eviCore for medical necessity determinations.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Electrical and Low Frequency US Bone Growth Stimulation SpineDefines medical necessity and non-coverage criteria for invasive and non-invasive electrical bone growth stimulation and low-intensity ultrasound for spinal fusion and failed fusion scenarios for plans administered by Cigna/eviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Facet Joint Injections/Medial Branch BlocksThis policy governs medical necessity criteria, procedural limits, and imaging/agent requirements for facet joint injections and medial branch nerve blocks (C2-3 to L5-S1) for Cigna health plans administered by eviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Hip Replacement/ ArthroplastyClinical coverage criteria for partial hip resurfacing, total hip resurfacing, partial and total hip replacement, and revision hip replacement — specifying when procedures are medically necessary or not. Applies to providers seeking authorization from eviCore for hip arthroplasty services.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Implantable Intrathecal Drug Delivery SystemsDefines medical necessity and coverage criteria for use of implantable intrathecal or epidural drug delivery systems (pain/baclofen pumps) for non-malignant chronic intractable pain and severe refractory spasticity/dystonia, and guidance for trials and exclusions; applies to Cigna-administered health benefit plans managed by eviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Lumbar Decompression, Corpectomy, and Related Device UseClinical coverage criteria for lumbar decompression procedures, repeat decompression, corpectomy, and use of interlaminar/interspinous devices for providers submitting authorization requests to evicore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Lumbar Microdiscectomy (Laminotomy, Laminectomy, or Hemilaminectomy)Defines medical necessity, urgent/emergent indications, credentialing, and coverage criteria for initial and repeat lumbar microdiscectomy and excision of extradural lesions for Cigna-administered plans; applies to providers requesting prior authorization and medical directors making coverage determinations.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Posterior Cervical FusionDefines medical necessity criteria, urgent/emergent indications, osteotomy indications, and general guidelines for posterior cervical fusion procedures for members of Cigna health benefit plans administered by eviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Primary Vertebral — Percutaneous Vertebral Augmentation and SacroplastyThis policy governs medical necessity review for percutaneous vertebral augmentation procedures (vertebroplasty, kyphoplasty, sacroplasty) for primary vertebral conditions and applies to health benefit plans administered by Cigna/EviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Regional Sympathetic BlocksMedical necessity and coverage criteria for regional sympathetic blocks (stellate ganglion and lumbar sympathetic chain blocks) for management of sympathetically mediated pain, primarily CRPS, applied to Cigna health benefit plans administered by eviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Sacroiliac Joint Fusion and StabilizationCriteria and coverage guidance for minimally invasive and open sacroiliac (SI) joint fusion and stabilization procedures for plans administered by Cigna and reviewed by eviCore; applies to providers seeking medical necessity determinations and prior authorization.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Sacroiliac Joint ProceduresMedical necessity and coverage criteria for diagnostic and therapeutic intra-articular sacroiliac joint injections and related sacral lateral branch procedures for members of Cigna health benefit plans administered by eviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Shoulder Surgery Arthroscopic and Open ProceduresClinical coverage policy for arthroscopic and open shoulder surgeries (including procedures for rotator cuff, labrum, impingement, instability, fractures, tumors, infection, and foreign bodies) used by Cigna plans administered by eviCore; intended to guide medical necessity determinations for providers and payers.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Spinal Cord and Dorsal Root Ganglion StimulationCoverage criteria and guidelines for trial and implantation of spinal cord stimulation (SCS) and dorsal root ganglion (DRG) stimulation for chronic neuropathic pain conditions under Cigna benefit plans administered by eviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-04Thoracic Decompression/DiscectomyClinical coverage criteria and prior authorization guidance for initial, repeat, and corpectomy thoracic decompression/discectomy procedures for members covered under Cigna plans administered by eviCore.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Sleep Disordered Breathing Diagnosis and Treatment Guidelines (Coverage Policy)Cigna/EviCore coverage policy governing medical necessity criteria, diagnostic testing, and initial treatment considerations for sleep-disordered breathing for members of health plans administered by Cigna; applies to providers requesting sleep studies and related services.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Cerebrovascular Endovascular Embolization and StentsClinical coverage policy governing prior-authorization, documentation, and medical necessity criteria for endovascular cerebrovascular procedures (embolization, angioplasty, stent placement, flow diverters) for members under Cigna benefit plans administered by eviCore. Applies to providers requesting authorization for cerebrovascular endovascular interventions.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-07Knee Replacement/ArthroplastyCoverage guidelines for partial, total, and revision knee replacement procedures and related definitions and general guidance for clinicians and medical directors administering Cigna health benefit plans.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-07Manipulation of the Spine Under Anesthesia (MUA)Defines clinical coverage criteria for manipulation of the spine under anesthesia (MUA) for Cigna-administered health benefit plans and explains when MUA is considered medically necessary or not medically necessary.All evicore updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-07Shoulder Arthroplasty/ Replacement/Resurfacing/Revision/ArthrodesisMedical necessity and coverage criteria for hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty, resurfacing, revision, and arthrodesis for shoulder conditions under Cigna-administered plans as applied by eviCore.All evicore updates
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Tool Description
Search Evicore coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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