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 1– 20 of 307 Results
Title Last Updated Category
Periodontal Maintenance Open a PDF 13.01.05 2024-05-30 Dental
Periodontal Scaling and Root Planing Open a PDF 13.01.04 2024-05-30 Dental
Dental Inlays and Onlays Open a PDF 13.01.03 2024-05-30 Dental
Dental Crowns and Veneers Open a PDF 13.01.02 2024-05-30 Dental
Dental Implants Open a PDF 13.01.01 2024-05-30 Dental
Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Services Open a PDF 7.03.01 2024-05-30 Anesthesiology
Bariatric and Metabolic Surgery Open a PDF 7.01.29 2024-05-30 Digestive System (Gastroenterology)
Maze Procedures for Atrial Fibrillation and Flutter Open a PDF 7.01.27 2024-05-30 Heart & Blood Vessels (Cardiovascular)
Bulking Agents for Treatment of Urinary or Fecal Incontinence Open a PDF 7.01.22 2024-05-30 Urinary System (Genitourinary)
Dental and Oral Care under Medical Plans Open a PDF 7.01.21 2024-05-30 Dental
Cryosurgical Tumor Ablation Open a PDF 7.01.03 2024-05-30 Cancer Treatment (Oncology)
Nuclear Breast Imaging Open a PDF 6.01.02 2024-05-30 Radiology (x-rays) & Imaging
Genetic Testing for Cardiac Ion Channelopathies Open a PDF 2.02.38 2024-05-30 Genetic Disease (Inherited Disease)
Genetic Testing for Familial Alzheimer's Disease Open a PDF 2.02.16 2024-05-30 Genetic Disease (Inherited Disease)
Bioimpedance Devices for Detection and Management of Lymphedema Open a PDF 2.01.52 2024-05-30 Miscellaneous
Evoked Potentials Open a PDF 2.01.27 2024-05-30 Nervous Systems (Neurology)
Hyperbaric Oxygen Therapy (HBOT) Open a PDF 2.01.07 2024-05-30 Miscellaneous
Lumbar Traction: Vertebral Axial Decompression and Home Lumbar Traction Devices Open a PDF 1.01.50 2024-05-30 Bone & Joints (Orthopedic)
Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes Open a PDF 1.01.30 2024-05-30 Diabetes (Endocrinology)
Experimental or Investigational Services Open a PDF 11.01.03 2024-05-29 Miscellaneous
Showing 1– 20 of 307 Results


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