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 1– 20 of 308 Results
Title Last Updated Category
Lysis of Epidural Adhesions (Effective 2025-10-15) Open a PDF 7.01.73 2025-07-11 Bone & Joints (Orthopedic)
Lumbar Fusion (Effective 2025-10-15) Open a PDF 7.01.117 2025-07-11 Bone & Joints (Orthopedic)
Prolotherapy (Effective 2025-10-15) Open a PDF 8.01.10 2025-07-11 Bone & Joints (Orthopedic)
Facet Joint Injections/ Medial Branch Blocks (Effective 2025-10-15) Open a PDF 7.01.116 2025-07-11 Bone & Joints (Orthopedic)
Epidural Steroid Injections (Effective 2025-10-15) Open a PDF 7.01.115 2025-07-11 Bone & Joints (Orthopedic)
Intradiscal Procedures (Effective 2025-10-15) Open a PDF 7.01.112 2025-07-11 Bone & Joints (Orthopedic)
Lumbar Microdiscectomy (Effective 2025-10-15) Open a PDF 7.01.98 2025-07-11 Bone & Joints (Orthopedic)
Hip Arthroplasty (Effective 2025-10-15) Open a PDF 7.01.96 2025-07-11 Bone & Joints (Orthopedic)
Artificial Cervical Intervertebral Disc (Effective 2025-10-15) Open a PDF 7.01.80 2025-07-11 Bone & Joints (Orthopedic)
Artificial Lumbar Intervertebral Disc (Effective 2025-10-15) Open a PDF 7.01.63 2025-07-11 Bone & Joints (Orthopedic)
Osteochondral Grafting of the Knee (Effective 2025-10-15) Open a PDF 7.01.59 2025-07-11 Bone & Joints (Orthopedic)
Spinal Cord Stimulation / Dorsal Column Stimulation (Effective 2025-10-15) Open a PDF 7.01.51 2025-07-11 Bone & Joints (Orthopedic)
Radiofrequency Facet and Sacroiliac Joint Ablation/ Denervation (Effective 2025-10-15) Open a PDF 7.01.42 2025-07-11 Bone & Joints (Orthopedic)
Autologous Chondrocyte Implantation (ACI) (Effective 2025-10-15) Open a PDF 7.01.38 2025-07-11 Bone & Joints (Orthopedic)
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty (Effective 2025-10-15) Open a PDF 6.01.17 2025-07-11 Bone & Joints (Orthopedic)
Speech Pathology and Therapy Open a PDF 8.01.13 2025-07-03 Therapy & Rehabilitation
Prenatal Genetic Testing Open a PDF 4.01.03 2025-07-03 Genetic Disease (Inherited Disease)
Biofeedback Open a PDF 2.01.09 2025-07-01 Alternative Medicine
Balloon Dilation of the Eustachian Tube (BDET) Open a PDF 7.01.101 2025-07-01 Ear, Nose & Throat (Otorhinolaryngology)
Minimally Invasive / Minimal Access Techniques for Lumbar Interbody Fusion Open a PDF 7.01.83 2025-07-01 Bone & Joints (Orthopedic)
Showing 1– 20 of 308 Results

 

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