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.

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Showing 201– 220 of 301 Results
Title Last Updated Category
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)
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 2023-07-18 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 2023-07-18 Dental
Periodontal Scaling and Root Planing Open a PDF 13.01.04 2023-07-18 Dental
Pharmacogenetics Open a PDF 2.02.30 2024-03-04 Genetic Disease (Inherited Disease)
Photodynamic Therapy (PDT) for Malignant Disease Open a PDF 8.01.06 2023-03-15 Cancer Treatment (Oncology)
Photodynamic Therapy for Malignant Disease (Effective 2024-06-14) Open a PDF 8.01.06 2024-03-14 Cancer Treatment (Oncology)
Phototherapy for the Treatment of Seasonal Affective Disorder Open a PDF 1.01.24 2023-11-02 Behavioral Health (Psychiatry/Psychology)
Physical Therapy (PT) Open a PDF 8.01.12 2023-12-09 Therapy & Rehabilitation
Plasmapheresis, Plasma Exchange and Apheresis Open a PDF 8.01.04 2024-03-04 Blood Disorders (Hematology)
Plugs for Fistula Repair Open a PDF 7.01.86 2024-03-28 Digestive System (Gastroenterology)
Showing 201– 220 of 301 Results

 

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