Policies and Procedures

How Are Prior Authorization Requests Reviewed?

All prior authorization requests are evaluated using nationally recognized, evidence-based clinical guidelines to determine medical necessity. Clinical criteria are applied in the following order of precedence:

Guideline	Source	When Applied
NCD	CMS (Federal)	Applied first – highest precedence when LCDs are not present
LCD	Medicare Administrative Contractors (MACs)	Applied and takes precedence when present for appropriate region/state
MCG	Milliman (Evidence-Based)	Applied when NCDs/LCDs do not fully address or are absent from the request

Each level builds on the prior: NCDs establish the federal coverage requirements, LCDs provide regional specificity where needed, and MCG helps address evidence-based gaps not covered by existing Medicare coverage determinations.

Consistent with Medicare Advantage requirements, when an applicable National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare Coverage Guidance (MCG) is unavailable, HealthTeam Advantage may apply internal coverage criteria based on current clinical evidence and nationally recognized guidelines, including MCG.

To search the Medicare Coverage Database, access MCG guidelines, or review HealthTeam Advantage policies, please visit the links below:

• • Medicare Coverage Database
  • MCG Guidelines
  • Effective 1/1/27: Cohere Health HTA Landing Page (Coming Soon)

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Current HealthTeam Advantage Policies in Effect

• • Policy 9.13 CNC-NC Retrospective Authorization Request Policy
  • Policy 9.20 CNC-NC Home Health Infusion Policy
  • Policy 9.70 CNC-NC Visual Field Assessment
  • HealthTeam Advantage Readmission Policy

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Effective March 1, 2027, the Additional Fourteen (14) Policies Go into Effect:

• • Cohere Medical Policy – Category III CPT Codes
  • Cohere Medicare Advantage Policy – Cervical Spinal Fusion
  • Cohere Medicare Advantage Policy – Great Toe Surgical Treatments
  • Cohere Medicare Advantage Policy – Intrathecal Pain Pumps
  • Cohere Medicare Advantage Policy – Knee Arthroplasty
  • Cohere Medicare Advantage Policy – Kyphectomy
  • Cohere Medicare Advantage Policy – Oral Appliance Therapy for Obstructive Sleep Apnea (OSA)
  • Cohere Medicare Advantage Policy – Positive Pressure Ventilation
  • Cohere Medicare Advantage Policy – Spinal Cord Stimulators
  • Cohere Medicare Advantage Policy – Spinal Decompression (Laminectomy, Laminotomy, Foraminotomy, and Discectomy)
  • Cohere Medicare Advantage Policy – Total Disc Arthroplasty
  • Cohere Medicare Advantage Policy – Vertebral Corpectomy

*final two policies coming soon