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 141– 160 of 291 Results
Title Last Updated Category
Lumbar Decompression Open a PDF 7.01.113 2025-04-17 Bone & Joints (Orthopedic)
Liver Transplantation Open a PDF 7.02.07 2025-04-08 Transplants
Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis Open a PDF 1.01.51 2024-09-24 Durable Medical Equipment & Supplies
Light and Laser Therapies for Dermatologic Conditions Open a PDF 8.01.21 2024-10-30 Skin (Dermatology)
Level of Care Criteria for Inpatient, Residential, Partial Hospital, and Intensive Outpatient Mental Health Services for Adults and Children Open a PDF 3.01.21 2025-04-17 Behavioral Health (Psychiatry/Psychology)
Left Atrial Appendage Closure Devices Open a PDF 7.01.92 2024-09-26 Heart & Blood Vessels (Cardiovascular)
Laboratory Testing for Transplantation Rejection Open a PDF 2.02.55 2025-03-14 Lab Tests (pathology)
Laboratory Testing for the Screening and Management of Prostate Cancer Open a PDF 2.02.48 2025-03-10 Genetic Disease (Inherited Disease)
Kidney Transplantation Open a PDF 7.02.04 2024-05-15 Transplants
Ketamine Infusion Therapy for the Treatment of Chronic Pain Syndromes Open a PDF 7.03.03 2025-04-01 Drug / Medications
Ketamine for the Treatment of Psychiatric Disorders Open a PDF 3.01.13 2025-01-30 Behavioral Health (Psychiatry/Psychology)
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms Open a PDF 2.02.53 2024-03-29 Lab Tests (pathology)
Intraocular Lens (IOL) Implants Open a PDF 9.01.14 2024-10-25 Eyes (Ophthalmology)
Showing 141– 160 of 291 Results

 

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