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 61– 80 of 297 Results
Title Last Updated Category
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)
Radiofrequency Tumor Ablation Open a PDF 7.01.32 2023-12-29 Cancer Treatment (Oncology)
Radiofrequency Treatment for Fecal Incontinence Open a PDF 7.01.66 2023-11-02 Digestive System (Gastroenterology)
Radiofrequency Facet and Sacroiliac Joint Ablation/Denervation Open a PDF 7.01.42 2023-06-14 Bone & Joints (Orthopedic)
Psychological Testing Open a PDF 3.01.02 2024-01-03 Behavioral Health (Psychiatry/Psychology)
Proton Beam Radiation Therapy Open a PDF 6.01.11 2023-09-15 Radiation Treatment
Proteomics-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Open a PDF 2.02.43 2023-09-08 Lab Tests (pathology)
Prolotherapy Open a PDF 8.01.10 2024-01-03 Bone & Joints (Orthopedic)
Private Rooms Open a PDF 12.01.06 2023-11-29 Miscellaneous
Prenatal Genetic Testing Open a PDF 4.01.03 2023-12-15 Genetic Disease (Inherited Disease)
Powered Compression Devices/Lymphedema Pumps Open a PDF 1.01.17 2023-12-21 Durable Medical Equipment & Supplies
Posturography Open a PDF 2.01.20 2023-11-02 Ear, Nose & Throat (Otorhinolaryngology)
Positron Emission Tomography (PET), Oncologic Applications Open a PDF 6.01.29 2024-04-19 Radiology (x-rays) & Imaging
Positron Emission Tomography (PET)- Non-Oncologic Applications Open a PDF 6.01.07 2023-12-15 Radiology (x-rays) & Imaging
Showing 61– 80 of 297 Results


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