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 101– 120 of 298 Results
Title Last Updated Category
Out-of-Network Services Open a PDF 11.01.14 2024-02-09 Miscellaneous
Osteochondral Grafting of the Knee Open a PDF 7.01.59 2023-06-14 Bone & Joints (Orthopedic)
Orthotics Open a PDF 1.01.25 2024-03-29 Bone & Joints (Orthopedic)
Oral Appliance for the Treatment of Obstructive Sleep Apnea Open a PDF 1.01.07 2023-12-21 Lungs (Respiratory)
Optical Coherence Tomography for Ophthalmologic Applications Open a PDF 9.01.10 2023-05-12 Eyes (Ophthalmology)
Ophthalmologic Techniques for the Diagnosis of Glaucoma (Scanning Laser Polarimetry and Scanning Laser Ophthalmoscopy) Open a PDF 9.01.06 2023-11-02 Eyes (Ophthalmology)
Ocular Photodynamic Therapy Open a PDF 8.01.11 2024-03-29 Eyes (Ophthalmology)
Occupational Therapy Open a PDF 8.01.17 2023-10-16 Therapy & Rehabilitation
Nutritional Therapy Open a PDF 8.01.18 2024-03-04 Food (Nutrition)
Nuclear Breast Imaging Open a PDF 6.01.02 2023-06-14 Radiology (x-rays) & Imaging
Non-Invasive-Prenatal Testing Open a PDF 2.02.25 2023-06-14 Lab Tests (pathology)
Neuropsychological Testing Open a PDF 2.01.50 2024-01-25 Nervous Systems (Neurology)
Negative Pressure Wound Therapy (Vacuum-Assisted Closure) Open a PDF 01.01.38 2023-10-09 Skin (Dermatology)
Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers Open a PDF 2.02.51 2024-03-29 Genetic Disease (Inherited Disease)
Molecular Testing in the Management of Pulmonary Nodules Open a PDF 2.02.58 2023-11-15 Lab Tests (pathology)
Molecular Testing for the Management of Pancreatic Cysts (e.g.,PancraGEN Pancreatic Risk Classifier) Open a PDF 2.02.39 2024-01-03 Lab Tests (pathology)
Showing 101– 120 of 298 Results


GDPR Notification Content