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 81– 100 of 305 Results
Title Last Updated Category
Dental Implants Open a PDF 13.01.01 2024-05-30 Dental
Dental Inlays and Onlays Open a PDF 13.01.03 2024-05-30 Dental
Disability Determination For Extension of Benefits After Coverage Termination Open a PDF 10.01.11 2023-09-08 Miscellaneous
Durable Medical Equipment Standard and Non-Standard Open a PDF 1.01.00 2024-02-27 Durable Medical Equipment & Supplies
Dynamic Adjustable Braces Open a PDF 1.01.35 2024-03-04 Bone & Joints (Orthopedic)
Electromagnetic Navigation Bronchoscopy Open a PDF 6.01.40 2024-01-25 Lungs (Respiratory)
Emergency Care Services Open a PDF 10.01.12 2024-03-29 Miscellaneous
Endobronchial Valves Open a PDF 7.01.106 2023-09-15 Lungs (Respiratory)
Endometrial Ablation Open a PDF 4.01.01 2024-03-04 Women's Health (Obstetrics & Gynecology)
Enteral Nutrition Open a PDF 10.01.03 2024-03-04 Food (Nutrition)
Erectile Dysfunction Open a PDF 7.01.30 2023-09-08 Urinary System (Genitourinary)
Evoked Potentials Open a PDF 2.01.27 2024-05-30 Nervous Systems (Neurology)
Experimental or Investigational Services Open a PDF 11.01.03 2024-05-29 Miscellaneous
External Prosthetic Devices Open a PDF 1.01.18 2024-03-11 Miscellaneous
Extracorporeal Photochemotherapy/Photopheresis Open a PDF 8.01.01 2023-11-02 Skin (Dermatology)
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds Open a PDF 2.01.31 2024-03-29 Bone & Joints (Orthopedic)
Extracranial Carotid and Vertebral Artery Angioplasty and Stents Open a PDF 7.01.60 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Showing 81– 100 of 305 Results


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