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 261– 280 of 305 Results
Title Last Updated Category
Bronchial Thermoplasty Open a PDF 7.01.88 2024-03-29 Lungs (Respiratory)
Breast Reconstruction Surgery Open a PDF 10.01.01 2023-09-08 Cosmetic / Reconstructive Surgery
Brachytherapy or Radioactive Seed Implantation for Prostate Cancer Open a PDF 6.01.16 2023-11-29 Radiation Treatment
Brachytherapy After Breast-Conserving Surgery, as Boost with Whole Breast Irradiation or Alone as Accelerated Partial Breast Irradiation Open a PDF 6.01.30 2024-02-15 Radiation Treatment
Bone Growth Stimulators Open a PDF 1.01.53 2024-04-29 Bone & Joints (Orthopedic)
Bone Densitometry/Bone Density Studies Open a PDF 6.01.05 2023-09-08 Radiology (x-rays) & Imaging
Blepharoplasty With or Without Levator Muscle Advancement Open a PDF 7.01.55 2024-03-29 Cosmetic / Reconstructive Surgery
Bioimpedance Devices for Detection and Management of Lymphedema Open a PDF 2.01.52 2024-05-30 Miscellaneous
Biofeedback Open a PDF 2.01.09 2023-07-18 Alternative Medicine
Bioengineered Tissue Products for Wound Treatment and Surgical Interventions Open a PDF 7.01.35 2024-03-29 Skin (Dermatology)
Biochemical Markers of Bone Turnover Open a PDF 2.02.18 2023-08-09 Lab Tests (pathology)
Behavioral Health Treatment for Gender Dysphoria Open a PDF 3.01.15 2023-08-09 Behavioral Health (Psychiatry/Psychology)
Bariatric and Metabolic Surgery Open a PDF 7.01.29 2024-05-30 Digestive System (Gastroenterology)
Balloon Sinus Ostial Dilation for Treatment of Chronic Rhinosinusitis (i.e., Balloon Sinuplasty) Open a PDF 7.01.85 2023-09-15 Ear, Nose & Throat (Otorhinolaryngology)
Balloon Dilation of the Eustachian Tube Open a PDF 7.01.101 2023-10-09 Ear, Nose & Throat (Otorhinolaryngology)
Automated Percutaneous Discectomy and Image-Guided, Minimally Invasive Decompression Open a PDF 7.01.16 2023-07-18 Bone & Joints (Orthopedic)
Autologous Hematopoietic Stem Cell Transplantation Open a PDF 7.02.03 2024-01-13 Transplants
Autologous Chrondrocyte Implantation Open a PDF 7.01.38 2023-06-14 Bone & Joints (Orthopedic)
Showing 261– 280 of 305 Results


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