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.

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Showing 1– 20 of 299 Results
Title Last Updated Category
Wheelchairs and Power Operated Vehicles Open a PDF 1.01.16 2024-03-28 Durable Medical Equipment & Supplies
Plugs for Fistula Repair Open a PDF 7.01.86 2024-03-28 Digestive System (Gastroenterology)
Spinal Cord Stimulation/Dorsal Column Stimulation Open a PDF 7.01.51 2024-03-14 Bone & Joints (Orthopedic)
Photodynamic Therapy for Malignant Disease (Effective 2024-06-14) Open a PDF 8.01.06 2024-03-14 Cancer Treatment (Oncology)
Spinal Injections (Epidural and Facet Injections) for Pain Management (Effective 2024-06-14) Open a PDF 7.01.87 2024-03-14 Bone & Joints (Orthopedic)
Standing Devices and Gait Trainers (Effective 2024-06-14) Open a PDF 1.01.46 2024-03-14 Durable Medical Equipment & Supplies
Transcranial Magnetic Stimulation Open a PDF 3.01.09 2024-03-11 Behavioral Health (Psychiatry/Psychology)
External Prosthetic Devices Open a PDF 1.01.18 2024-03-11 Miscellaneous
Intensity Modulated Radiation Therapy (IMRT) Open a PDF 6.01.24 2024-03-11 Radiation Treatment
Total Parenteral Nutrition (TPN) or Hyperalimentation Open a PDF 11.01.04 2024-03-04 Food (Nutrition)
Experimental or Investigational Services Open a PDF 11.01.03 2024-03-04 Miscellaneous
Enteral Nutrition Open a PDF 10.01.03 2024-03-04 Food (Nutrition)
Aqueous Drainage Devices (Stents and Shunts) Open a PDF 9.01.18 2024-03-04 Eyes (Ophthalmology)
Nutritional Therapy Open a PDF 8.01.18 2024-03-04 Food (Nutrition)
Plasmapheresis, Plasma Exchange and Apheresis Open a PDF 8.01.04 2024-03-04 Blood Disorders (Hematology)
Angioplasty of Intracranial Atherosclerotic Stenoses with or without Stenting Open a PDF 7.01.70 2024-03-04 Nervous Systems (Neurology)
Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors Open a PDF 7.01.69 2024-03-04 Radiation Treatment
Cosmetic and Reconstructive Procedures Open a PDF 7.01.11 2024-03-04 Cosmetic / Reconstructive Surgery
Focal Therapies for Prostate Cancer Treatment Open a PDF 7.01.01 2024-03-04 Urinary System (Genitourinary)
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation Open a PDF 6.01.17 2024-03-04 Bone & Joints (Orthopedic)
Showing 1– 20 of 299 Results

 

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