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 201– 220 of 300 Results
Title Last Updated Category
Focal Therapies for Prostate Cancer Treatment Open a PDF 7.01.01 2024-03-04 Urinary System (Genitourinary)
Flow Cytometry Open a PDF 2.02.57 2023-08-09 Lab Tests (pathology)
Fecal Microbiota Transplantation Open a PDF 2.01.48 2023-10-09 Digestive System (Gastroenterology)
Family Therapy for Individuals with a Diagnosis of Mental Illness and/or Substance Use Disorder Open a PDF 3.01.05 2024-03-04 Behavioral Health (Psychiatry/Psychology)
Extracranial Carotid and Vertebral Artery Angioplasty and Stents Open a PDF 7.01.60 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds Open a PDF 2.01.31 2024-03-29 Bone & Joints (Orthopedic)
Extracorporeal Photochemotherapy/Photopheresis Open a PDF 8.01.01 2023-11-02 Skin (Dermatology)
External Prosthetic Devices Open a PDF 1.01.18 2024-03-11 Miscellaneous
Experimental or Investigational Services Open a PDF 11.01.03 2024-03-04 Miscellaneous
Evoked Potentials Open a PDF 2.01.27 2023-06-14 Nervous Systems (Neurology)
Erectile Dysfunction Open a PDF 7.01.30 2023-09-08 Urinary System (Genitourinary)
Enteral Nutrition Open a PDF 10.01.03 2024-03-04 Food (Nutrition)
Endometrial Ablation Open a PDF 4.01.01 2024-03-04 Women's Health (Obstetrics & Gynecology)
Endobronchial Valves Open a PDF 7.01.106 2023-09-15 Lungs (Respiratory)
Emergency Care Services Open a PDF 10.01.12 2024-03-29 Miscellaneous
Electromagnetic Navigation Bronchoscopy Open a PDF 6.01.40 2024-01-25 Lungs (Respiratory)
Dynamic Adjustable Braces Open a PDF 1.01.35 2024-03-04 Bone & Joints (Orthopedic)
Durable Medical Equipment Standard and Non-Standard Open a PDF 1.01.00 2024-02-27 Durable Medical Equipment & Supplies
Showing 201– 220 of 300 Results


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