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 101– 120 of 307 Results
Title Last Updated Category
Family Therapy for Individuals with a Diagnosis of Mental Illness and/or Substance Use Disorder Open a PDF 3.01.05 2024-03-04 Behavioral Health (Psychiatry/Psychology)
Fecal Microbiota Transplantation Open a PDF 2.01.48 2023-10-09 Digestive System (Gastroenterology)
Flow Cytometry Open a PDF 2.02.57 2023-08-09 Lab Tests (pathology)
Focal Therapies for Prostate Cancer Treatment Open a PDF 7.01.01 2024-03-04 Urinary System (Genitourinary)
Foot Orthotics Open a PDF 1.01.41 2024-06-28 Feet (Podiatry)
Functional Electrical Stimulation (FES) and Neuromuscular Electrical Stimulation (NMES) Open a PDF 1.01.48 2022-09-13 Durable Medical Equipment & Supplies
Gastric Electrical Stimulation Open a PDF 7.01.64 2024-01-25 Digestive System (Gastroenterology)
Gender Affirming Surgery and Treatments for Commercial and Medicare Advantage Members Open a PDF 7.01.84 2023-03-07 Miscellaneous
Gender Reassignment/Gender Affirming Surgery and Treatments for Medicaid Managed Care Plan (MMCP) and Health and Recovery Plan (HARP) Members Open a PDF 7.01.105 2023-02-15 Miscellaneous
Gene Expression Profiling for Cutaneous Melanoma Open a PDF 2.02.52 2023-10-09 Cancer Treatment (Oncology)
Genetic Assay of Tumor Tissue to Determine Prognosis and Treatment of Breast Cancer (Effective 2024-07-15) Open a PDF 2.02.27 2024-04-15 Genetic Disease (Inherited Disease)
Genetic Assay of Tumor Tissue to Determine Prognosis of Breast Cancer (Oncotype Dx Breast Recurrence Score, MammaPrint) Open a PDF 2.02.27 2023-09-08 Genetic Disease (Inherited Disease)
Genetic Testing for Cardiac Ion Channelopathies Open a PDF 2.02.38 2024-05-30 Genetic Disease (Inherited Disease)
Genetic Testing for Cystic Fibrosis Open a PDF 2.02.17 2023-08-09 Genetic Disease (Inherited Disease)
Genetic Testing for Familial Alzheimer's Disease Open a PDF 2.02.16 2024-05-30 Genetic Disease (Inherited Disease)
Genetic Testing for Inherited Disorders Open a PDF 2.02.03 2024-01-03 Genetic Disease (Inherited Disease)
Germline Genetic Testing for Hereditary Cancers Open a PDF 2.02.60 2024-06-27 Genetic Disease (Inherited Disease)
Growth Factors for Wound Healing Open a PDF 2.01.24 2024-01-25 Skin (Dermatology)
Heart & Heart/Lung Transplant Open a PDF 7.02.06 2023-10-16 Transplants
Showing 101– 120 of 307 Results

 

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