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 141– 160 of 303 Results
Title Last Updated Category
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms Open a PDF 2.02.53 2024-03-29 Lab Tests (pathology)
Keratoprosthesis Open a PDF 9.01.15 2024-03-29 Eyes (Ophthalmology)
Ketamine for the Treatment of Psychiatric Disorders Open a PDF 3.01.13 2024-01-25 Behavioral Health (Psychiatry/Psychology)
Ketamine Infusion Therapy for the Treatment of Chronic Pain Syndromes Open a PDF 7.03.03 2024-03-29 Drug / Medications
Kidney Transplantation (Effective 2024-08-15) Open a PDF 7.02.04 2024-05-15 Transplants
Kidney Transplantation Open a PDF 7.02.04 2023-10-16 Transplants
Laboratory Testing for Heart and Kidney Transplantation Rejection Open a PDF 2.02.55 2023-08-24 Lab Tests (pathology)
Laboratory Testing for Prostate Cancer Screening and Management Open a PDF 2.02.48 2024-01-04 Genetic Disease (Inherited Disease)
Left Atrial Appendage Closure Devices Open a PDF 7.01.92 2023-10-16 Heart & Blood Vessels (Cardiovascular)
Level of Care Criteria for Inpatient, Residential, Partial Hospital, and Intensive Outpatient Mental Health Services for Adults and Children Open a PDF 3.01.21 2023-11-29 Behavioral Health (Psychiatry/Psychology)
Light and Laser Therapies for Dermatologic Conditions Open a PDF 8.01.21 2023-09-08 Skin (Dermatology)
Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis Open a PDF 1.01.51 2023-10-09 Durable Medical Equipment & Supplies
Liver Transplantation Open a PDF 7.02.07 2023-11-15 Transplants
Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening Open a PDF 6.01.19 2024-04-15 Radiology (x-rays) & Imaging
Lumbar Decompression Open a PDF 7.01.97 2024-06-28 Bone & Joints (Orthopedic)
Showing 141– 160 of 303 Results


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