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 41– 60 of 307 Results
Title Last Updated Category
Genetic Testing for Familial Alzheimer's Disease Open a PDF 2.02.16 2024-05-30 Genetic Disease (Inherited Disease)
Bioimpedance Devices for Detection and Management of Lymphedema Open a PDF 2.01.52 2024-05-30 Miscellaneous
Evoked Potentials Open a PDF 2.01.27 2024-05-30 Nervous Systems (Neurology)
Hyperbaric Oxygen Therapy (HBOT) Open a PDF 2.01.07 2024-05-30 Miscellaneous
Lumbar Traction: Vertebral Axial Decompression and Home Lumbar Traction Devices Open a PDF 1.01.50 2024-05-30 Bone & Joints (Orthopedic)
Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes Open a PDF 1.01.30 2024-05-30 Diabetes (Endocrinology)
Experimental or Investigational Services Open a PDF 11.01.03 2024-05-29 Miscellaneous
Kidney Transplantation (Effective 2024-08-15) Open a PDF 7.02.04 2024-05-15 Transplants
Pacemakers and Cardiac Resynchronization Therapy (CRT) Devices (Effective 2024-08-15) Open a PDF 7.01.58 2024-05-15 Heart & Blood Vessels (Cardiovascular)
Implantable Cardioverter Defibrillator (ICD) (Effective 2024-08-15) Open a PDF 7.01.06 2024-05-15 Heart & Blood Vessels (Cardiovascular)
Positron Emission Tomography (PET) - Non-Oncologic Applications (Effective 2024-08-15) Open a PDF 6.01.07 2024-05-15 Radiology (x-rays) & Imaging
Cranial Orthotics (Effective 2024-08-15) Open a PDF 1.01.32 2024-05-15 Children's Health (Pediatrics)
Inflammatory Markers of Coronary Artery Disease Risk Open a PDF 2.02.15 2024-05-14 Lab Tests (pathology)
Colorectal Cancer Screening and Surveillance Open a PDF 2.01.51 2024-05-14 Digestive System (Gastroenterology)
Measurement of Serum Antibodies to Tumor Necrosis Factor Blockers Open a PDF 2.02.47 2024-05-14 Lab Tests (pathology)
Pharmacogenetics Open a PDF 2.02.30 2024-05-14 Genetic Disease (Inherited Disease)
Urinary Tumor Markers for Bladder Cancer Open a PDF 2.02.12 2024-05-14 Lab Tests (pathology)
Standing Devices and Gait Trainers Open a PDF 1.01.46 2024-05-13 Durable Medical Equipment & Supplies
Acupuncture and Auricular Electrostimulation Open a PDF 8.01.20 2024-05-02 Alternative Medicine
Showing 41– 60 of 307 Results


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