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 241– 260 of 305 Results
Title Last Updated Category
Continuous Passive Motion Device in the Home Setting Open a PDF 1.01.02 2023-11-02 Durable Medical Equipment & Supplies
Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes Open a PDF 1.01.30 2024-05-30 Diabetes (Endocrinology)
Continuing Day Treatment Programs Open a PDF 3.01.20 2024-04-29 Behavioral Health (Psychiatry/Psychology)
Computerized Motion Diagnostic Imaging (CMDI)/Gait Analysis Open a PDF 2.01.13 2023-08-15 Bone & Joints (Orthopedic)
Computed Tomography (CT) for Coronary Calcium Scoring Open a PDF 6.01.13 2024-01-15 Radiology (x-rays) & Imaging
Comfort, Convenience, Custodial or Cosmetic Services Open a PDF 11.01.11 2024-01-03 Miscellaneous
Colorectal Cancer Screening and Surveillance Open a PDF 2.01.51 2024-05-14 Digestive System (Gastroenterology)
Cognitive Rehabilitation Open a PDF 8.01.19 2023-11-02 Therapy & Rehabilitation
Cochlear Implants and Auditory Brainstem Implants Open a PDF 7.01.26 2024-03-29 Ear, Nose & Throat (Otorhinolaryngology)
Clinical Trials Open a PDF 11.01.10 2024-06-27 Miscellaneous
Circulating Tumor DNA for Management of Cancer (Liquid Biopsy) Open a PDF 2.02.56 2024-02-09 Lab Tests (pathology)
Chromosomal Microarray (CMA) Analysis for Prenatal Evaluation and Evaluation of Patients with Developmental Delay/ Intellectual Disability or Autism Spectrum Disorder Open a PDF 2.02.42 2024-01-03 Genetic Disease (Inherited Disease)
Chiropractic Care Open a PDF 10.01.02 2023-08-09 Chiropractic
Chelation Therapy Open a PDF 8.01.03 2023-11-02 Blood Disorders (Hematology)
Cardiac/Coronary Computed Tomographic Angiography (Cardiac/Coronary CTA): Contrast-Enhanced Open a PDF 6.01.34 2024-01-15 Radiology (x-rays) & Imaging
Cardiac Resynchronization Therapy (Biventricular Pacemakers) for the Treatment of Heart Failure Open a PDF 7.01.58 2023-09-08 Heart & Blood Vessels (Cardiovascular)
Cardiac Rehabilitation Open a PDF 8.01.14 2023-11-02 Therapy & Rehabilitation
Showing 241– 260 of 305 Results


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