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 41– 60 of 298 Results
Title Last Updated Category
Urine Drug Testing Open a PDF 2.02.50 2024-01-17 Lab Tests (pathology)
Cardiac/Coronary Computed Tomographic Angiography (Cardiac/Coronary CTA): Contrast-Enhanced (Effective 2024-04-15) Open a PDF 6.01.34 2024-01-15 Radiology (x-rays) & Imaging
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy (Effective 2024-04-15) Open a PDF 6.01.12 2024-01-15 Radiation Treatment
Computed Tomography (CT) for Coronary Calcium Scoring (Effective 2024-04-15) Open a PDF 6.01.13 2024-01-15 Radiology (x-rays) & Imaging
Autologous Hematopoietic Stem Cell Transplantation Open a PDF 7.02.03 2024-01-13 Transplants
Laboratory Testing for Prostate Cancer Screening and Management Open a PDF 2.02.48 2024-01-04 Genetic Disease (Inherited Disease)
Assisted Reproductive Technologies – In Vitro Fertilization Open a PDF 4.01.05 2024-01-03 Women's Health (Obstetrics & Gynecology)
Comfort, Convenience, Custodial or Cosmetic Services Open a PDF 11.01.11 2024-01-03 Miscellaneous
Management of Dry Eye Syndrome and Meibomian Gland Dysfunction (e.g., LipiFlow) Open a PDF 9.01.19 2024-01-03 Eyes (Ophthalmology)
Prolotherapy Open a PDF 8.01.10 2024-01-03 Bone & Joints (Orthopedic)
Treatment of Tinnitus Open a PDF 8.01.07 2024-01-03 Ear, Nose & Throat (Otorhinolaryngology)
Spinal Manipulation Under Anesthesia Open a PDF 7.01.76 2024-01-03 Bone & Joints (Orthopedic)
Lysis of Epidural Adhesions (Epidural Adhesiolysis) Open a PDF 7.01.73 2024-01-03 Bone & Joints (Orthopedic)
Percutaneous Intradiscal Electrothermal Annuloplasty (IDET/IDTA, PIRFT, Biacuplasty) and Intradiscal Injections Open a PDF 7.01.17 2024-01-03 Bone & Joints (Orthopedic)
Psychological Testing Open a PDF 3.01.02 2024-01-03 Behavioral Health (Psychiatry/Psychology)
Chromosomal Microarray (CMA) Analysis for Prenatal Evaluation and Evaluation of Patients with Developmental Delay/ Intellectual Disability or Autism Spectrum Disorder Open a PDF 2.02.42 2024-01-03 Genetic Disease (Inherited Disease)
Molecular Testing for the Management of Pancreatic Cysts (e.g.,PancraGEN Pancreatic Risk Classifier) Open a PDF 2.02.39 2024-01-03 Lab Tests (pathology)
Genetic Testing for Inherited Disorders Open a PDF 2.02.03 2024-01-03 Genetic Disease (Inherited Disease)
Treatment of Hirsutism/ Hypertrichosis (Hair Removal) Open a PDF 2.01.38 2024-01-03 Cosmetic / Reconstructive Surgery
Showing 41– 60 of 298 Results

 

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