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 81– 100 of 294 Results
Title Last Updated Category
Blepharoplasty and Brow Ptosis Repair Open a PDF 7.01.55 2025-04-01 Cosmetic / Reconstructive Surgery
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.45 2025-04-01 Digestive System (Gastroenterology)
Cochlear Implants and Auditory Brainstem Implants Open a PDF 7.01.26 2025-04-01 Ear, Nose & Throat (Otorhinolaryngology)
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds Open a PDF 2.01.31 2025-04-01 Bone & Joints (Orthopedic)
Orthotics Open a PDF 1.01.25 2025-04-01 Bone & Joints (Orthopedic)
Varicose Vein Treatments Open a PDF 7.01.47 2025-04-01 Cosmetic / Reconstructive Surgery
Radiopharmaceuticals for the Treatment of Cancer Open a PDF 6.01.44 2025-04-01 Cancer Treatment (Oncology)
Magnetic Resonance Spectroscopy (MRS) Open a PDF 6.01.03 2025-04-01 Radiology (x-rays) & Imaging
Facet Joint Injections/ Medial Branch Blocks Open a PDF 7.01.116 2025-04-01 Bone & Joints (Orthopedic)
Epidural Steroid Injections Open a PDF 7.01.115 2025-04-01 Bone & Joints (Orthopedic)
Laboratory Testing for Transplantation Rejection Open a PDF 2.02.55 2025-03-14 Lab Tests (pathology)
Allogeneic Hematopoietic (STEM) Cell Transplantation (HSCT) Open a PDF 7.02.02 2025-03-14 Transplants
Urinary Tumor Markers for Bladder and Urothelial Cancers Open a PDF 2.02.12 2025-03-10 Lab Tests (pathology)
Sleep Studies Open a PDF 2.01.28 2025-03-03 Sleep Medicine
Oral Appliance for the Treatment of Obstructive Sleep Apnea Open a PDF 1.01.07 2025-02-28 Lungs (Respiratory)
Photodynamic Therapy for Malignant Disease Open a PDF 8.01.06 2025-02-27 Cancer Treatment (Oncology)
Ambulance Air Open a PDF 11.01.06 2025-02-27 Miscellaneous
Experimental or Investigational Services Open a PDF 11.01.03 2025-02-27 Miscellaneous
Ambulance: Land/Ground Open a PDF 10.01.07 2025-02-27 Miscellaneous
Plugs for Fistula Repair Open a PDF 7.01.86 2025-02-27 Digestive System (Gastroenterology)
Showing 81– 100 of 294 Results

 

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