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 161– 180 of 301 Results
Title Last Updated Category
Lumbar Fusion for Adults Open a PDF 7.01.90 2023-08-15 Bone & Joints (Orthopedic)
Lumbar Microdiscectomy Open a PDF 7.01.98 2023-08-15 Bone & Joints (Orthopedic)
Lumbar Traction: Vertebral Axial Decompression and Home Lumbar Traction Devices Open a PDF 1.01.50 2024-05-30 Bone & Joints (Orthopedic)
Lung and Lobar Lung Transplant Open a PDF 7.02.10 2024-04-29 Transplants
Lysis of Epidural Adhesions (Epidural Adhesiolysis) Open a PDF 7.01.73 2024-01-03 Bone & Joints (Orthopedic)
Magnetic Resonance Imaging‒Prostate/Multiparametric MRI Open a PDF 6.01.46 2024-04-15 Radiology (x-rays) & Imaging
Magnetic Resonance Spectroscopy (MRS) Open a PDF 6.01.03 2024-04-15 Radiology (x-rays) & Imaging
Management of Dry Eye Syndrome and Meibomian Gland Dysfunction (e.g., LipiFlow) Open a PDF 9.01.19 2024-01-03 Eyes (Ophthalmology)
Maze Procedures for Atrial Fibrillation and Flutter Open a PDF 7.01.27 2024-05-30 Heart & Blood Vessels (Cardiovascular)
Measurable Residual Disease Assessment Testing Open a PDF 2.02.54 2023-12-01 Lab Tests (pathology)
Measurement of Serum Antibodies to Tumor Necrosis Factor Blockers Open a PDF 2.02.47 2024-05-14 Lab Tests (pathology)
Medical Policy Title Magnetic Esophageal Ring/Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.89 2024-04-29 Digestive System (Gastroenterology)
Medical Response to Contamination from Terrorist Attacks Open a PDF 11.01.09 2023-09-08 Miscellaneous
Medical Services for Transgender and Gender Diverse Individuals Open a PDF 11.01.26 2023-11-02 Behavioral Health (Psychiatry/Psychology)
Showing 161– 180 of 301 Results


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