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.

To view drug policies, guidelines and supporting documentation, please visit our View Drug Policies page.

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Showing 21– 40 of 285 Results
Title Last Updated Category
Total Parenteral Nutrition (TPN) or Hyperalimentation Open a PDF 11.01.04 2025-02-27 Food (Nutrition)
Total Hip Resurfacing, Metal on Metal Open a PDF 7.01.74 2024-10-02 Bone & Joints (Orthopedic)
Tibial Nerve Stimulation (TNS) for Voiding Dysfunction Open a PDF 8.01.22 2025-04-23 Nervous Systems (Neurology)
Thermal Ablation for Solid Tumor Treatment Open a PDF 7.01.111 2025-01-09 Cancer Treatment (Oncology)
Testing for the Use of Biologic Therapeutics for the Treatment of Inflammatory Disorders Open a PDF 2.02.47 2024-12-12 Lab Tests (pathology)
Temporomandibular Joint Disorders (TMJD) Open a PDF 11.01.17 2024-12-04 Bone & Joints (Orthopedic)
Surgical Management of Sleep Disorders Open a PDF 7.01.41 2025-05-05 Sleep Medicine
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Open a PDF 6.01.12 2024-10-30 Radiation Treatment
Standing Devices and Gait Trainers Open a PDF 1.01.46 2025-02-27 Durable Medical Equipment & Supplies
Spinal Cord Stimulation/Dorsal Column Stimulation Open a PDF 7.01.51 2024-11-18 Bone & Joints (Orthopedic)
Speech Pathology and Therapy Open a PDF 8.01.13 2025-05-30 Therapy & Rehabilitation
Showing 21– 40 of 285 Results

 

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