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 201– 220 of 306 Results
Title Last Updated Category
Optical Coherence Tomography for Ophthalmologic Applications Open a PDF 9.01.10 2024-04-29 Eyes (Ophthalmology)
Oral Appliance for the Treatment of Obstructive Sleep Apnea Open a PDF 1.01.07 2023-12-21 Lungs (Respiratory)
Orthotics Open a PDF 1.01.25 2024-06-28 Bone & Joints (Orthopedic)
Osteochondral Grafting of the Knee Open a PDF 7.01.59 2023-06-14 Bone & Joints (Orthopedic)
Out-of-Network Services Open a PDF 11.01.14 2024-02-09 Miscellaneous
Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome Open a PDF 4.01.10 2023-10-09 Women's Health (Obstetrics & Gynecology)
Pacemakers and Cardiac Resynchronization Therapy (CRT) Devices (Effective 2024-08-15) Open a PDF 7.01.58 2024-05-15 Heart & Blood Vessels (Cardiovascular)
Pancreas Transplant Open a PDF 7.02.01 2023-02-15 Transplants
Pancreas Transplant: (Pancreas Transplant Alone, Pancreas Transplant after Kidney Transplant, Simultaneous Pancreas Kidney Transplant): Islet Cell Transplant (Effective 2024-07-15) Open a PDF 7.02.01 2024-04-15 Transplants
Partial Hospitalization for Substance Use Disorders Open a PDF 3.01.18 2023-09-18 Behavioral Health (Psychiatry/Psychology)
Patient Lifts (e.g., Hoyer, Saralift), Seat Lift Chair Mechanisms and Ceiling Lifts Open a PDF 1.01.08 2023-08-09 Home Care
Pelvic Floor Electrical Stimulation as a Treatment for Urinary or Fecal Incontinence Open a PDF 1.01.19 2024-06-28 Urinary System (Genitourinary)
Percutaneous Intradiscal Electrothermal Annuloplasty (IDET/IDTA, PIRFT, Biacuplasty) and Intradiscal Injections Open a PDF 7.01.17 2024-01-03 Bone & Joints (Orthopedic)
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation Open a PDF 6.01.17 2024-03-04 Bone & Joints (Orthopedic)
Periodontal Maintenance Open a PDF 13.01.05 2024-05-30 Dental
Periodontal Scaling and Root Planing Open a PDF 13.01.04 2024-05-30 Dental
Pharmacogenetics Open a PDF 2.02.30 2024-05-14 Genetic Disease (Inherited Disease)
Photodynamic Therapy for Malignant Disease Open a PDF 8.01.06 2024-03-14 Cancer Treatment (Oncology)
Showing 201– 220 of 306 Results


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