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.

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Showing 41– 60 of 294 Results
Title Last Updated Category
Spinal Cord Stimulation/Dorsal Column Stimulation Open a PDF 7.01.51 2024-03-14 Bone & Joints (Orthopedic)
Speech Pathology and Therapy Open a PDF 8.01.13 2023-09-08 Therapy & Rehabilitation
Small Bowel and Multivisceral Transplants in Adults and Children Open a PDF 7.02.05 2023-04-18 Transplants
Sleep Studies Open a PDF 2.01.28 2024-02-09 Sleep Medicine
Skilled Nursing Facility Care / Level of Care Criteria Open a PDF 11.01.21 2023-09-08 Miscellaneous
Shoulder Arthroplasty (Total, Partial, Reverse) Open a PDF 7.01.95 2023-07-18 Bone & Joints (Orthopedic)
Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease Open a PDF 2.02.19 2023-11-29 Lab Tests (pathology)
Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors Open a PDF 7.01.69 2024-03-04 Radiation Treatment
Second Medical and Surgical Opinions Open a PDF 10.01.10 2023-05-12 Miscellaneous
Screening for Vitamin D Deficiency Open a PDF 2.02.45 2023-09-08 Lab Tests (pathology)
Sacroiliac Joint Fusion/Stabilization: Open and Percutaneous Methods Open a PDF 7.01.93 2024-02-29 Bone & Joints (Orthopedic)
Sacral Nerve Stimulation Open a PDF 7.01.10 2023-12-29 Nervous Systems (Neurology)
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy Open a PDF 7.01.103 2023-05-12 Nervous Systems (Neurology)
Reduction Mammaplasty (Mammoplasty) Open a PDF 7.01.39 2023-08-09 Cosmetic / Reconstructive Surgery
Radiopharmaceuticals for the Treatment of Cancer Open a PDF 6.01.44 2023-10-16 Cancer Treatment (Oncology)
Showing 41– 60 of 294 Results

 

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