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 81– 100 of 300 Results
Title Last Updated Category
Positive Airway Pressure Devices CPAP, BiPAP, APAP and Noninvasive Positive Pressure Ventilators Open a PDF 1.01.06 2024-01-25 Sleep Medicine
Plugs for Fistula Repair Open a PDF 7.01.86 2024-03-28 Digestive System (Gastroenterology)
Plasmapheresis, Plasma Exchange and Apheresis Open a PDF 8.01.04 2024-03-04 Blood Disorders (Hematology)
Physical Therapy (PT) Open a PDF 8.01.12 2023-12-09 Therapy & Rehabilitation
Phototherapy for the Treatment of Seasonal Affective Disorder Open a PDF 1.01.24 2023-11-02 Behavioral Health (Psychiatry/Psychology)
Photodynamic Therapy for Malignant Disease (Effective 2024-06-14) Open a PDF 8.01.06 2024-03-14 Cancer Treatment (Oncology)
Photodynamic Therapy (PDT) for Malignant Disease Open a PDF 8.01.06 2023-03-15 Cancer Treatment (Oncology)
Pharmacogenetics Open a PDF 2.02.30 2024-03-04 Genetic Disease (Inherited Disease)
Periodontal Scaling and Root Planing Open a PDF 13.01.04 2023-07-18 Dental
Periodontal Maintenance Open a PDF 13.01.05 2023-07-18 Dental
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation Open a PDF 6.01.17 2024-03-04 Bone & Joints (Orthopedic)
Percutaneous Intradiscal Electrothermal Annuloplasty (IDET/IDTA, PIRFT, Biacuplasty) and Intradiscal Injections Open a PDF 7.01.17 2024-01-03 Bone & Joints (Orthopedic)
Pelvic Floor Electrical Stimulation as a Treatment for Urinary or Fecal Incontinence Open a PDF 1.01.19 2023-07-18 Urinary System (Genitourinary)
Patient Lifts (e.g., Hoyer, Saralift), Seat Lift Chair Mechanisms and Ceiling Lifts Open a PDF 1.01.08 2023-08-09 Home Care
Partial Hospitalization for Substance Use Disorders Open a PDF 3.01.18 2023-09-18 Behavioral Health (Psychiatry/Psychology)
Pancreas Transplant: (Pancreas Transplant Alone, Pancreas Transplant after Kidney Transplant, Simultaneous Pancreas Kidney Transplant): Islet Cell Transplant (Effective 2024-07-15) Open a PDF 7.02.01 2024-04-15 Transplants
Pancreas Transplant Open a PDF 7.02.01 2023-02-15 Transplants
Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome Open a PDF 4.01.10 2023-10-09 Women's Health (Obstetrics & Gynecology)
Showing 81– 100 of 300 Results


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