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 221– 240 of 305 Results
Title Last Updated Category
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
Disability Determination For Extension of Benefits After Coverage Termination Open a PDF 10.01.11 2023-09-08 Miscellaneous
Dental Inlays and Onlays Open a PDF 13.01.03 2024-05-30 Dental
Dental Implants Open a PDF 13.01.01 2024-05-30 Dental
Dental Crowns and Veneers Open a PDF 13.01.02 2024-05-30 Dental
Dental and Oral Care under Medical Plans Open a PDF 7.01.21 2024-05-30 Dental
Deep Brain Stimulation Open a PDF 7.01.23 2024-05-02 Nervous Systems (Neurology)
CT (Computed Tomography) Perfusion Imaging of the Brain Open a PDF 6.01.37 2024-04-15 Radiology (x-rays) & Imaging
Cryotherapy (Cold Therapy) Devices Open a PDF 1.01.21 2024-06-28 Bone & Joints (Orthopedic)
Cryosurgical Tumor Ablation Open a PDF 7.01.03 2024-05-30 Cancer Treatment (Oncology)
Cranial Orthotics (Effective 2024-08-15) Open a PDF 1.01.32 2024-05-15 Children's Health (Pediatrics)
Cranial Orthotics Open a PDF 1.01.32 2024-01-03 Children's Health (Pediatrics)
Coverage for Dependents with Disabilities Open a PDF 10.01.08 2023-11-29 Miscellaneous
Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Services Open a PDF 7.03.01 2024-05-30 Anesthesiology
Cosmetic and Reconstructive Procedures Open a PDF 7.01.11 2024-03-04 Cosmetic / Reconstructive Surgery
Showing 221– 240 of 305 Results


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