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 281– 300 of 307 Results
Title Last Updated Category
Surgical Stockings and Compression Garments Open a PDF 1.01.14 2024-04-12 Durable Medical Equipment & Supplies
Temporomandibular Joint Disorders (TMJD) Open a PDF 11.01.17 2023-11-29 Bone & Joints (Orthopedic)
Tibial Nerve Stimulation (TNS) for Voiding Dysfunction Open a PDF 8.01.22 2024-04-29 Nervous Systems (Neurology)
Total Hip Resurfacing, Metal on Metal Open a PDF 7.01.74 2024-06-28 Bone & Joints (Orthopedic)
Total Parenteral Nutrition (TPN) or Hyperalimentation Open a PDF 11.01.04 2024-03-04 Food (Nutrition)
Transcatheter Closure Devices for Cardiac Defects and Patent Ductus Arteriosus Open a PDF 7.01.34 2023-08-09 Heart & Blood Vessels (Cardiovascular)
Transcatheter Heart Valve Procedures Open a PDF 7.01.109 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Transcranial Magnetic Stimulation Open a PDF 3.01.09 2024-03-11 Behavioral Health (Psychiatry/Psychology)
Transcutaneous and Percutaneous Electrical Nerve Stimulation as a Treatment for Pain and Other Conditions Open a PDF 1.01.01 2023-12-21 Durable Medical Equipment & Supplies
Transcutaneous and Percutaneous Nerve Stimulation as a Treatment for Pain and Other Conditions (Effective 2024-07-15) Open a PDF 1.01.01 2024-06-28 Durable Medical Equipment & Supplies
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.45 2024-03-29 Digestive System (Gastroenterology)
Treatment of Gambling Disorder and Other Repetitive Behaviors Open a PDF 3.01.19 2024-03-04 Behavioral Health (Psychiatry/Psychology)
Treatment of Hirsutism/ Hypertrichosis (Hair Removal) Open a PDF 2.01.38 2024-01-03 Cosmetic / Reconstructive Surgery
Treatment of Tinnitus Open a PDF 8.01.07 2024-01-03 Ear, Nose & Throat (Otorhinolaryngology)
Tumor-Treatment Field Therapy Open a PDF 6.01.45 2024-03-29 Cancer Treatment (Oncology)
Urinary Tumor Markers for Bladder Cancer Open a PDF 2.02.12 2024-05-14 Lab Tests (pathology)
Urine Drug Testing Open a PDF 2.02.50 2024-01-17 Lab Tests (pathology)
Vagus Nerve Stimulation and Vagus Nerve Blocking Therapy Open a PDF 7.01.05 2023-12-29 Nervous Systems (Neurology)
Varicose Vein Treatments Open a PDF 7.01.47 2023-11-15 Cosmetic / Reconstructive Surgery
Showing 281– 300 of 307 Results


GDPR Notification Content