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 1– 20 of 305 Results
Title Last Updated Category
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders Open a PDF 6.01.27 2023-11-15 Digestive System (Gastroenterology)
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Open a PDF 2.02.46 2024-06-27 Genetic Disease (Inherited Disease)
Wheelchairs and Power Operated Vehicles Open a PDF 1.01.16 2024-03-28 Durable Medical Equipment & Supplies
Vitrectomy Chair/ Face-Down Positioning System Open a PDF 1.01.52 2024-04-29 Durable Medical Equipment & Supplies
Vision Therapy Open a PDF 9.01.04 2023-11-29 Eyes (Ophthalmology)
Ventricular Assist Devices Open a PDF 7.01.07 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Varicose Vein Treatments Open a PDF 7.01.47 2023-11-15 Cosmetic / Reconstructive Surgery
Vagus Nerve Stimulation and Vagus Nerve Blocking Therapy Open a PDF 7.01.05 2023-12-29 Nervous Systems (Neurology)
Urine Drug Testing Open a PDF 2.02.50 2024-01-17 Lab Tests (pathology)
Urinary Tumor Markers for Bladder Cancer Open a PDF 2.02.12 2024-05-14 Lab Tests (pathology)
Tumor-Treatment Field Therapy Open a PDF 6.01.45 2024-03-29 Cancer Treatment (Oncology)
Treatment of Tinnitus Open a PDF 8.01.07 2024-01-03 Ear, Nose & Throat (Otorhinolaryngology)
Treatment of Hirsutism/ Hypertrichosis (Hair Removal) Open a PDF 2.01.38 2024-01-03 Cosmetic / Reconstructive Surgery
Treatment of Gambling Disorder and Other Repetitive Behaviors Open a PDF 3.01.19 2024-03-04 Behavioral Health (Psychiatry/Psychology)
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.45 2024-03-29 Digestive System (Gastroenterology)
Transcutaneous and Percutaneous Nerve Stimulation as a Treatment for Pain and Other Conditions (Effective 2024-07-15) Open a PDF 1.01.01 2024-06-28 Durable Medical Equipment & Supplies
Transcutaneous and Percutaneous Electrical Nerve Stimulation as a Treatment for Pain and Other Conditions Open a PDF 1.01.01 2023-12-21 Durable Medical Equipment & Supplies
Showing 1– 20 of 305 Results


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