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 241– 260 of 302 Results
Title Last Updated Category
Radiofrequency Facet and Sacroiliac Joint Ablation/Denervation Open a PDF 7.01.42 2023-06-14 Bone & Joints (Orthopedic)
Radiofrequency Treatment for Fecal Incontinence Open a PDF 7.01.66 2023-11-02 Digestive System (Gastroenterology)
Radiofrequency Tumor Ablation Open a PDF 7.01.32 2023-12-29 Cancer Treatment (Oncology)
Radiopharmaceuticals for the Treatment of Cancer Open a PDF 6.01.44 2023-10-16 Cancer Treatment (Oncology)
Reduction Mammaplasty (Mammoplasty) Open a PDF 7.01.39 2023-08-09 Cosmetic / Reconstructive Surgery
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy Open a PDF 7.01.103 2024-04-29 Nervous Systems (Neurology)
Sacral Nerve Stimulation Open a PDF 7.01.10 2023-12-29 Nervous Systems (Neurology)
Sacroiliac Joint Fusion/Stabilization: Open and Percutaneous Methods Open a PDF 7.01.93 2024-02-29 Bone & Joints (Orthopedic)
Screening for Vitamin D Deficiency Open a PDF 2.02.45 2023-09-08 Lab Tests (pathology)
Second Medical and Surgical Opinions Open a PDF 10.01.10 2024-04-29 Miscellaneous
Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors Open a PDF 7.01.69 2024-04-30 Radiation Treatment
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease Open a PDF 2.02.19 2023-11-29 Lab Tests (pathology)
Shoulder Arthroplasty (Total, Partial, Reverse) Open a PDF 7.01.95 2023-07-18 Bone & Joints (Orthopedic)
Skilled Nursing Facility Care / Level of Care Criteria Open a PDF 11.01.21 2023-09-08 Miscellaneous
Sleep Studies Open a PDF 2.01.28 2024-02-09 Sleep Medicine
Showing 241– 260 of 302 Results

 

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