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 308 Results
Title Last Updated Category
Bariatric and Metabolic Surgery Open a PDF 7.01.29 2024-07-03 Digestive System (Gastroenterology)
Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) Open a PDF 7.01.104 2024-07-03 Urinary System (Genitourinary)
Bioengineered Tissue Products for Wound Treatment and Surgical Interventions Open a PDF 7.01.35 2024-06-28 Skin (Dermatology)
Transcutaneous and Percutaneous Nerve Stimulation as a Treatment for Pain and Other Conditions (Effective 2024-07-15) Open a PDF 1.01.01 2024-06-28 Durable Medical Equipment & Supplies
Minimally Invasive / Minimal Access Techniques for Lumbar Interbody Fusion Open a PDF 7.01.83 2024-06-28 Bone & Joints (Orthopedic)
Speech Pathology and Therapy Open a PDF 8.01.13 2024-06-28 Therapy & Rehabilitation
Lumbar Decompression Open a PDF 7.01.97 2024-06-28 Bone & Joints (Orthopedic)
Shoulder Arthroplasty (Total, Partial, Reverse) Open a PDF 7.01.95 2024-06-28 Bone & Joints (Orthopedic)
Total Hip Resurfacing, Metal on Metal Open a PDF 7.01.74 2024-06-28 Bone & Joints (Orthopedic)
Lysis of Epidural Adhesions (Epidural Adhesiolysis) Open a PDF 7.01.73 2024-06-28 Bone & Joints (Orthopedic)
Artificial Hearts Open a PDF 7.01.65 2024-06-28 Heart & Blood Vessels (Cardiovascular)
Radiofrequency Tumor Ablation Open a PDF 7.01.32 2024-06-28 Cancer Treatment (Oncology)
Automated Percutaneous Discectomy and Image-Guided, Minimally Invasive Decompression Open a PDF 7.01.16 2024-06-28 Bone & Joints (Orthopedic)
Applied Behavioral Analysis Open a PDF 3.01.11 2024-06-28 Behavioral Health (Psychiatry/Psychology)
Measurable Residual Disease (MRD) Assessment Testing Open a PDF 2.02.54 2024-06-28 Lab Tests (pathology)
Biofeedback Open a PDF 2.01.09 2024-06-28 Alternative Medicine
Home Prothrombin Time Monitor Device Open a PDF 1.01.44 2024-06-28 Home Care
Home Automatic External Defibrillators (AEDs) and Wearable Cardioverter Defibrillators (WCDs) Open a PDF 1.01.42 2024-06-28 Heart & Blood Vessels (Cardiovascular)
Foot Orthotics Open a PDF 1.01.41 2024-06-28 Feet (Podiatry)
Orthotics Open a PDF 1.01.25 2024-06-28 Bone & Joints (Orthopedic)
Showing 1– 20 of 308 Results


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