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 181– 200 of 304 Results
Title Last Updated Category
Medical/Non-Surgical Weight Management Programs and Services Open a PDF 11.01.01 2023-12-09 Miscellaneous
Medically Necessary Services Open a PDF 11.01.15 2023-11-02 Miscellaneous
Minimally Invasive / Minimal Access Techniques for Lumbar Interbody Fusion Open a PDF 7.01.83 2024-06-28 Bone & Joints (Orthopedic)
Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) Open a PDF 7.01.104 2024-07-03 Urinary System (Genitourinary)
Molecular Marker Testing of the Thyroid Open a PDF 2.02.49 2024-06-27 Genetic Disease (Inherited Disease)
Molecular Testing for the Management of Pancreatic Cysts (e.g.,PancraGEN Pancreatic Risk Classifier) Open a PDF 2.02.39 2024-01-03 Lab Tests (pathology)
Molecular Testing in the Management of Pulmonary Nodules Open a PDF 2.02.58 2023-11-15 Lab Tests (pathology)
Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers Open a PDF 2.02.51 2024-06-27 Genetic Disease (Inherited Disease)
Negative Pressure Wound Therapy (Vacuum-Assisted Closure) Open a PDF 01.01.38 2023-10-09 Skin (Dermatology)
Neuropsychological Testing Open a PDF 2.01.50 2024-01-25 Nervous Systems (Neurology)
Non-Invasive-Prenatal Testing Open a PDF 2.02.25 2024-04-29 Lab Tests (pathology)
Nuclear Breast Imaging Open a PDF 6.01.02 2024-05-30 Radiology (x-rays) & Imaging
Nutritional Therapy Open a PDF 8.01.18 2024-03-04 Food (Nutrition)
Occupational Therapy Open a PDF 8.01.17 2023-10-16 Therapy & Rehabilitation
Ocular Photodynamic Therapy Open a PDF 8.01.11 2024-03-29 Eyes (Ophthalmology)
Ophthalmologic Techniques for the Diagnosis of Glaucoma (Scanning Laser Polarimetry and Scanning Laser Ophthalmoscopy) Open a PDF 9.01.06 2023-11-02 Eyes (Ophthalmology)
Showing 181– 200 of 304 Results


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