View Medical Policies

For certain member contracts, the Health Plan has delegated utilization management of the following services to eviCore Healthcare MSI, LLC d/b/a eviCore Healthcare: implantable cardiac devices, radiology/imaging, radiation therapy, and musculoskeletal services (large joint replacement, pain management, and spine services). The Health Plan has adopted eviCore’s medical policies and guidelines as a basis for the determination of medical necessity and appropriateness of care.

Please refer member-specific questions to the Customer Care number on the back of the member card. Final determination of coverage is subject to the member’s benefits and eligibility on the date of service.

Showing 1– 20 of 304 Results
Title Last Updated Category
Abdominoplasty and Panniculectomy Open a PDF 7.01.53 2023-05-12 Cosmetic / Reconstructive Surgery
Ablation, Implants, and Sinus Stents for Nasal Conditions Open a PDF 7.01.99 2023-12-15 Ear, Nose & Throat (Otorhinolaryngology)
Ablation/Denervation Techniques for Knee Pain Open a PDF 7.01.100 2023-07-18 Bone & Joints (Orthopedic)
Acupuncture and Auricular Electrostimulation Open a PDF 8.01.20 2024-05-02 Alternative Medicine
Airway Clearance Devices: Oscillatory Devices (e.g., High frequency Chest Wall Compression, Flutter valve, Intrapulmonary Percussive Ventilator), Mechanical Percussors and Assisted Cough and Mechanical Insufflation Devices (e.g., In-Exsufflator) Open a PDF 1.01.15 2023-11-29 Lungs (Respiratory)
Allergen Immunotherapy Open a PDF 2.01.11 2023-07-13 Ear, Nose & Throat (Otorhinolaryngology)
Allergy Testing Open a PDF 2.01.10 2023-07-13 Ear, Nose & Throat (Otorhinolaryngology)
Allogeneic Hematopoietic Stem Cell Transplantation Open a PDF 7.02.02 2023-11-29 Transplants
Alopecia (Hair Loss) Open a PDF 2.01.36 2024-01-03 Cosmetic / Reconstructive Surgery
Ambulance Air Open a PDF 11.01.06 2024-03-29 Miscellaneous
Ambulance: Land/Ground Open a PDF 10.01.07 2024-03-29 Miscellaneous
Ambulatory Event Monitors Open a PDF 2.01.03 2023-11-29 Heart & Blood Vessels (Cardiovascular)
Angioplasty of Intracranial Atherosclerotic Stenoses with or without Stenting Open a PDF 7.01.70 2024-03-04 Nervous Systems (Neurology)
Applied Behavioral Analysis Open a PDF 3.01.11 2024-06-28 Behavioral Health (Psychiatry/Psychology)
Aqueous Drainage Devices (Stents and Shunts) Open a PDF 9.01.18 2024-03-04 Eyes (Ophthalmology)
Artificial Cervical Intervertebral Disc Open a PDF 7.01.80 2023-06-14 Bone & Joints (Orthopedic)
Showing 1– 20 of 304 Results


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