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 141– 160 of 295 Results
Title Last Updated Category
Lumbar Traction: Vertebral Axial Decompression and Home Lumbar Traction Devices Open a PDF 1.01.50 2024-02-27 Bone & Joints (Orthopedic)
Lumbar Microdiscectomy Open a PDF 7.01.98 2023-08-15 Bone & Joints (Orthopedic)
Lumbar Fusion for Adults Open a PDF 7.01.90 2023-08-15 Bone & Joints (Orthopedic)
Lumbar Decompression Open a PDF 7.01.97 2024-04-12 Bone & Joints (Orthopedic)
Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening Open a PDF 6.01.19 2024-04-15 Radiology (x-rays) & Imaging
Liver Transplantation Open a PDF 7.02.07 2023-11-15 Transplants
Limb Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis Open a PDF 1.01.51 2023-10-09 Durable Medical Equipment & Supplies
Light and Laser Therapies for Dermatologic Conditions Open a PDF 8.01.21 2023-09-08 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 2023-11-29 Behavioral Health (Psychiatry/Psychology)
Left Atrial Appendage Closure Devices Open a PDF 7.01.92 2023-10-16 Heart & Blood Vessels (Cardiovascular)
Laboratory Testing for Prostate Cancer Screening and Management Open a PDF 2.02.48 2024-01-04 Genetic Disease (Inherited Disease)
Laboratory Testing for Heart and Kidney Transplantation Rejection Open a PDF 2.02.55 2023-08-24 Lab Tests (pathology)
Kidney Transplantation Open a PDF 7.02.04 2023-10-16 Transplants
Showing 141– 160 of 295 Results


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