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 21– 40 of 308 Results
Title Last Updated Category
Cryotherapy (Cold Therapy) Devices Open a PDF 1.01.21 2024-06-28 Bone & Joints (Orthopedic)
Pelvic Floor Electrical Stimulation as a Treatment for Urinary or Fecal Incontinence Open a PDF 1.01.19 2024-06-28 Urinary System (Genitourinary)
Clinical Trials Open a PDF 11.01.10 2024-06-27 Miscellaneous
Molecular Marker Testing of the Thyroid Open a PDF 2.02.49 2024-06-27 Genetic Disease (Inherited Disease)
Germline Genetic Testing for Hereditary Cancers Open a PDF 2.02.60 2024-06-27 Genetic Disease (Inherited Disease)
Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers Open a PDF 2.02.51 2024-06-27 Genetic Disease (Inherited Disease)
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Open a PDF 2.02.46 2024-06-27 Genetic Disease (Inherited Disease)
Powered Compression Devices/Lymphedema Pumps (Effective 2024-09-16) Open a PDF 2024-06-24 Durable Medical Equipment & Supplies
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
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)
Showing 21– 40 of 308 Results


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