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 21– 40 of 308 Results
Title Last Updated Category
Maze Procedures for Atrial Fibrillation and Flutter Open a PDF 7.01.27 2025-07-01 Heart & Blood Vessels (Cardiovascular)
Sacral Nerve Stimulation Open a PDF 7.01.10 2025-07-01 Nervous Systems (Neurology)
Positron Emission Tomography (PET)- Non-Oncologic Applications Open a PDF 6.01.07 2025-07-01 Radiology (x-rays) & Imaging
Applied Behavioral Analysis Open a PDF 3.01.11 2025-07-01 Behavioral Health (Psychiatry/Psychology)
Hyperbaric Oxygen Therapy (HBOT) Open a PDF 2.01.07 2025-07-01 Miscellaneous
Home Automatic External Defibrillators (AEDs) and Wearable Cardioverter Defibrillators (WCDs) Open a PDF 1.01.42 2025-07-01 Heart & Blood Vessels (Cardiovascular)
Foot Orthotics Open a PDF 1.01.41 2025-07-01 Feet (Podiatry)
Cryotherapy (Cold Therapy) Devices Open a PDF 1.01.21 2025-07-01 Bone & Joints (Orthopedic)
Comfort, Convenience, Custodial or Cosmetic Services Open a PDF 11.01.11 2025-06-30 Miscellaneous
Circulating Tumor DNA for Management of Cancer (Liquid Biopsy) Open a PDF 2.02.56 2025-06-27 Lab Tests (pathology)
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Open a PDF 2.02.46 2025-06-27 Genetic Disease (Inherited Disease)
Bioengineered Tissue Products for Wound Treatment and Surgical Interventions Open a PDF 7.01.35 2025-06-27 Skin (Dermatology)
Transarterial Radioembolization (TARE) for Hepatic Tumors Open a PDF 7.01.69 2025-06-25 Radiation Treatment
Predictive Testing for Pancreatic Cancer Open a PDF 2.02.39 2025-06-20 Lab Tests (pathology)
Laboratory Testing for the Screening and Management of Prostate Cancer Open a PDF 2.02.48 2025-06-20 Genetic Disease (Inherited Disease)
Measurable Residual Disease (MRD) Assessment Testing Open a PDF 2.02.54 2025-06-20 Lab Tests (pathology)
Transcatheter Heart Valve Procedures (Effective 2025-09-16) Open a PDF 7.01.109 2025-06-16 Heart & Blood Vessels (Cardiovascular)
Tumor-Treatment Fields Therapy (Effective 2025-09-16) Open a PDF 6.01.45 2025-06-16 Cancer Treatment (Oncology)
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms (Effective 2025-09-16) Open a PDF 2.02.53 2025-06-16 Lab Tests (pathology)
Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Services Open a PDF 7.03.01 2025-06-16 Anesthesiology
Showing 21– 40 of 308 Results

 

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