• Commercial and Medicare Only
• As of September 1, 2026, prior authorization is no longer required for in-plan home care services.

Radiation Oncology
Commercial and Medicare Advantage

• EviCore Radiation Oncology Guidelines

Cardiac & Vascular Intervention
Commercial and Medicare Advantage

• DHC – Adults: EviCore Cardiac Imaging Guidelines
• DHC – Pediatrics: EviCore Pediatric Cardiology Imaging Guidelines
• CRID – Adult and Pediatrics: Cardiac Implantable Devices (CID) Guidelines

Musculoskeletal: Joint Procedures
Commercial, Medicare Advantage and Medicaid

• CMM-311: Knee Replacement/Arthroplasty
• CMM-312: Knee Surgery- Arthroscopic and Open Procedures
• CMM-313: Hip Replacement/Arthroplasty
• CMM-314:Hip Surgery[1]Arthroscopic and Open Procedures
• CMM-315: Shoulder Surgery – Arthroscopic and Open Procedures Guidelines
• CMM-318: Shoulder Arthroplasty/Replacement/Resurfacing/Revision/Arthrodesis

Musculoskeletal: Spine
Commercial, Medicare Advantage and Medicaid

• CMM-600 Preface to Spine Surgery Guidelines
• CMM-601 Anterior Cervical Discectomy and Fusion
• CMM-602 Cervical Total Disc Arthroplasty
• CMM-603 Posterior Cervical Decompression
• CMM-604 Posterior Cervical Fusion
• CMM-605 Cervical Microdiscectomy
• CMM-606 Lumbar Microdiscectomy
• CMM-607 Primary Vertebral Augmentation and Sacroplasty
• CMM-608 Lumbar Decompression
• CMM-609: Lumbar Fusion (Arthrodesis)
• CMM-610 Lumbar Total Disc Arthroplasty
• CMM-611 SI Joint Fusion Stabilization
• CMM-612: Grafts
• CMM-613: Thoracic Decompression and Discectomy Guidelines
• CMM-614 Thoracic and Thoracolumbar Fusion (Arthrodesis) Guidelines
• CMM-615 Electrical US Bone Stimulation

EviCore will be providing training to practices on these new programs in December. Further information will be provided in November.

• Commercial, Medicare & Medicaid Lines of Business
  • Abdominal Panniculectomy: Medicare InterQual criteria adopted; minor updates.
  • Bone Grafts and Stabilization Devices: Added FDA-approved INFUSE™ indication for TLIF.
  • Cosmetic and Reconstructive Procedures: Added criteria for infant ear molding systems and scar/keloid revision; coding tables updated.
  • Hyperbaric Oxygen Therapy: Minor updates; Medicare InterQual HBOT criteria adopted.
  • Leadless Cardiac Pacemaker: Added Medicare InterQual criteria for CED studies and clinical trials.
  • HIV-Associated Lipodystrophy Syndrome: Added Medicare InterQual criteria for dermal injections.
  • Long-Term Acute Care (LTAC): InterQual criteria adopted for Commercial and Medicare.
  • Prostate Procedures: Medicare InterQual criteria adopted for waterjet ablation and cryosurgery.
  • Sacroiliac Joint Fusion: InterQual criteria adopted; definitions updated.
  • Sleep Disordered Breathing: Added CPT® 64568 (Hypoglossal Nerve Stimulator) with prior authorization requirements.

• Commercial & Medicaid Lines of Business
  • Hospice and Palliative Care: Minor criteria and reference updates.

• Commercial & Medicare Lines of Business
  • Infertility Treatment: Added sperm washing criteria; minor policy updates.

Medical policies are available on the Health New England website at https://healthnewengland.org/Providers/Resources.