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 41– 60 of 309 Results
Title Last Updated Category
Speech Pathology and Therapy Open a PDF 8.01.13 2025-07-03 Therapy & Rehabilitation
Specialty Enclosure Bed Systems Open a PDF 1.01.56 2025-02-14 Durable Medical Equipment & Supplies
Small Bowel and Multivisceral Transplants in Adults and Children Open a PDF 7.02.05 2025-04-01 Transplants
Sleep Studies Open a PDF 2.01.28 2025-03-03 Sleep Medicine
Skilled Nursing Facility Care / Level of Care Criteria Open a PDF 11.01.21 2024-07-29 Miscellaneous
Shoulder Arthroplasty (Total, Partial, Reverse) Open a PDF 7.01.95 2024-06-28 Bone & Joints (Orthopedic)
Shoulder Arthroplasty (Total, Partial, Reverse, Revision and Resurfacing) (Effective 2025-10-15) Open a PDF 7.01.95 2025-07-15 Bone & Joints (Orthopedic)
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease Open a PDF 2.02.19 2024-12-04 Lab Tests (pathology)
Second Medical and Surgical Opinions Open a PDF 10.01.10 2025-04-23 Miscellaneous
Sacroiliac Joint Fusion/Stabilization: Open and Percutaneous Methods Open a PDF 7.01.93 2024-11-01 Bone & Joints (Orthopedic)
Sacroiliac Joint Fusion or Stabilization (Effective 2025-10-15) Open a PDF 7.01.93 2025-07-15 Bone & Joints (Orthopedic)
Sacral Nerve Stimulation Open a PDF 7.01.10 2025-07-01 Nervous Systems (Neurology)
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy Open a PDF 7.01.103 2025-05-30 Nervous Systems (Neurology)
Reduction Mammaplasty (Mammoplasty) Open a PDF 7.01.39 2025-01-29 Cosmetic / Reconstructive Surgery
Radiopharmaceuticals for the Treatment of Cancer Open a PDF 6.01.44 2025-04-01 Cancer Treatment (Oncology)
Showing 41– 60 of 309 Results

 

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