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 221– 240 of 303 Results
Title Last Updated Category
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)
Positive Airway Pressure Devices CPAP, BiPAP, APAP and Noninvasive Positive Pressure Ventilators Open a PDF 1.01.06 2024-01-25 Sleep Medicine
Positron Emission Tomography (PET) - Non-Oncologic Applications (Effective 2024-08-15) Open a PDF 6.01.07 2024-05-15 Radiology (x-rays) & Imaging
Positron Emission Tomography (PET)- Non-Oncologic Applications Open a PDF 6.01.07 2023-12-15 Radiology (x-rays) & Imaging
Positron Emission Tomography (PET), Oncologic Applications Open a PDF 6.01.29 2024-04-19 Radiology (x-rays) & Imaging
Posturography Open a PDF 2.01.20 2023-11-02 Ear, Nose & Throat (Otorhinolaryngology)
Powered Compression Devices/Lymphedema Pumps Open a PDF 1.01.17 2023-12-21 Durable Medical Equipment & Supplies
Prenatal Genetic Testing Open a PDF 4.01.03 2023-12-15 Genetic Disease (Inherited Disease)
Private Rooms Open a PDF 12.01.06 2023-11-29 Miscellaneous
Prolotherapy Open a PDF 8.01.10 2024-01-03 Bone & Joints (Orthopedic)
Proteomics-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Open a PDF 2.02.43 2023-09-08 Lab Tests (pathology)
Proton Beam Radiation Therapy Open a PDF 6.01.11 2023-09-15 Radiation Treatment
Psychological Testing Open a PDF 3.01.02 2024-01-03 Behavioral Health (Psychiatry/Psychology)
Radiofrequency Facet and Sacroiliac Joint Ablation/Denervation Open a PDF 7.01.42 2023-06-14 Bone & Joints (Orthopedic)
Showing 221– 240 of 303 Results


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