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 61– 80 of 306 Results
Title Last Updated Category
Colorectal Cancer Screening and Surveillance Open a PDF 2.01.51 2024-05-14 Digestive System (Gastroenterology)
Comfort, Convenience, Custodial or Cosmetic Services Open a PDF 11.01.11 2024-01-03 Miscellaneous
Computed Tomography (CT) for Coronary Calcium Scoring Open a PDF 6.01.13 2024-01-15 Radiology (x-rays) & Imaging
Computerized Motion Diagnostic Imaging (CMDI)/Gait Analysis Open a PDF 2.01.13 2023-08-15 Bone & Joints (Orthopedic)
Continuing Day Treatment Programs Open a PDF 3.01.20 2024-04-29 Behavioral Health (Psychiatry/Psychology)
Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes Open a PDF 1.01.30 2024-05-30 Diabetes (Endocrinology)
Continuous Passive Motion Device in the Home Setting Open a PDF 1.01.02 2023-11-02 Durable Medical Equipment & Supplies
Cosmetic and Reconstructive Procedures Open a PDF 7.01.11 2024-03-04 Cosmetic / Reconstructive Surgery
Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Services Open a PDF 7.03.01 2024-05-30 Anesthesiology
Coverage for Dependents with Disabilities Open a PDF 10.01.08 2023-11-29 Miscellaneous
Cranial Orthotics (Effective 2024-08-15) Open a PDF 1.01.32 2024-05-15 Children's Health (Pediatrics)
Cranial Orthotics Open a PDF 1.01.32 2024-01-03 Children's Health (Pediatrics)
Cryosurgical Tumor Ablation Open a PDF 7.01.03 2024-05-30 Cancer Treatment (Oncology)
Cryotherapy (Cold Therapy) Devices Open a PDF 1.01.21 2024-06-28 Bone & Joints (Orthopedic)
CT (Computed Tomography) Perfusion Imaging of the Brain Open a PDF 6.01.37 2024-04-15 Radiology (x-rays) & Imaging
Deep Brain Stimulation Open a PDF 7.01.23 2024-05-02 Nervous Systems (Neurology)
Dental and Oral Care under Medical Plans Open a PDF 7.01.21 2024-05-30 Dental
Dental Crowns and Veneers Open a PDF 13.01.02 2024-05-30 Dental
Showing 61– 80 of 306 Results


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