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 261– 280 of 287 Results
Title Last Updated Category
Bariatric and Metabolic Surgery Open a PDF 7.01.29 2025-05-30 Digestive System (Gastroenterology)
Balloon Sinus Ostial Dilation for Treatment of Chronic Rhinosinusitis (i.e., Balloon Sinuplasty) Open a PDF 7.01.85 2024-09-04 Ear, Nose & Throat (Otorhinolaryngology)
Balloon Dilation of the Eustachian Tube (BDET) Open a PDF 7.01.101 2025-07-01 Ear, Nose & Throat (Otorhinolaryngology)
Autologous Hematopoietic (Stem) Cell Transplantation (HSCT) Open a PDF 7.02.03 2025-01-16 Transplants
Autologous Chondrocyte Implantation (ACI) Open a PDF 7.01.38 2024-11-01 Bone & Joints (Orthopedic)
Augmentative and Alternative Communication Systems (e.g., Speech-generating Devices) Open a PDF 1.01.03 2024-09-04 Durable Medical Equipment & Supplies
Assisted Reproductive Technologies – In Vitro Fertilization Open a PDF 4.01.05 2024-12-30 Women's Health (Obstetrics & Gynecology)
Artificial Lumbar Intervertebral Disc Open a PDF 7.01.63 2025-04-17 Bone & Joints (Orthopedic)
Artificial Cervical Intervertebral Disc Open a PDF 7.01.80 2025-04-17 Bone & Joints (Orthopedic)
Aqueous Drainage Devices (Stents and Shunts) Open a PDF 9.01.18 2025-01-30 Eyes (Ophthalmology)
Applied Behavioral Analysis Open a PDF 3.01.11 2025-07-01 Behavioral Health (Psychiatry/Psychology)
Angioplasty and Stenting of Extracranial, Intracranial and Vertebral Arteries Open a PDF 7.01.110 2024-12-26 Nervous Systems (Neurology)
Ambulatory Event Monitors Open a PDF 2.01.03 2024-12-04 Heart & Blood Vessels (Cardiovascular)
Showing 261– 280 of 287 Results

 

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