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.

To view drug policies, guidelines and supporting documentation, please visit our View Drug Policies page.

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Showing 121– 140 of 303 Results
Title Last Updated Category
Minimally Invasive / Minimal Access Techniques for Lumbar Interbody Fusion Open a PDF 7.01.83 2025-07-01 Bone & Joints (Orthopedic)
Medically Necessary Services Open a PDF 11.01.15 2025-01-14 Miscellaneous
Medical Services for Transgender and Gender Diverse Individuals Open a PDF 11.01.26 2024-09-04 Behavioral Health (Psychiatry/Psychology)
Medical Response to Contamination from Terrorist Attacks Open a PDF 11.01.09 2024-09-04 Miscellaneous
Measurable Residual Disease (MRD) Assessment Testing Open a PDF 2.02.54 2025-06-20 Lab Tests (pathology)
Maze Procedures for Atrial Fibrillation and Flutter Open a PDF 7.01.27 2025-07-01 Heart & Blood Vessels (Cardiovascular)
Management of Dry Eye Syndrome and Meibomian Gland Dysfunction (e.g., LipiFlow) Open a PDF 9.01.19 2024-12-30 Eyes (Ophthalmology)
Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.89 2025-04-23 Digestive System (Gastroenterology)
Magnetic Resonance Spectroscopy (MRS) Open a PDF 6.01.03 2025-04-01 Radiology (x-rays) & Imaging
Magnetic Resonance Imaging (MRI) of the Prostate Open a PDF 6.01.46 2024-12-30 Radiology (x-rays) & Imaging
Lysis of Epidural Adhesions (Epidural Adhesiolysis) Open a PDF 7.01.73 2024-06-28 Bone & Joints (Orthopedic)
Lysis of Epidural Adhesions (Effective 2025-10-15) Open a PDF 7.01.73 2025-07-11 Bone & Joints (Orthopedic)
Lung and Lobar Lung Transplant Open a PDF 7.02.10 2025-05-30 Transplants
Lumbar Microdiscectomy (Effective 2025-10-15) Open a PDF 7.01.98 2025-07-11 Bone & Joints (Orthopedic)
Lumbar Microdiscectomy Open a PDF 7.01.98 2025-04-17 Bone & Joints (Orthopedic)
Showing 121– 140 of 303 Results

 

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