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 161– 180 of 307 Results
Title Last Updated Category
Laboratory Testing for Heart and Kidney Transplantation Rejection Open a PDF 2.02.55 2023-08-24 Lab Tests (pathology)
Kidney Transplantation (Effective 2024-08-15) Open a PDF 7.02.04 2024-05-15 Transplants
Kidney Transplantation Open a PDF 7.02.04 2023-10-16 Transplants
Ketamine Infusion Therapy for the Treatment of Chronic Pain Syndromes Open a PDF 7.03.03 2024-03-29 Drug / Medications
Ketamine for the Treatment of Psychiatric Disorders Open a PDF 3.01.13 2024-01-25 Behavioral Health (Psychiatry/Psychology)
Keratoprosthesis Open a PDF 9.01.15 2024-03-29 Eyes (Ophthalmology)
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms Open a PDF 2.02.53 2024-03-29 Lab Tests (pathology)
Intravascular Ultrasound (IVUS) Open a PDF 6.01.09 2023-08-09 Heart & Blood Vessels (Cardiovascular)
Intraocular Lens (IOL) Implants Open a PDF 9.01.14 2023-11-02 Eyes (Ophthalmology)
Intervertebral Disc Decompression: Laser (Laser Discectomy) and Radiofrequency Coblation (Disc Nucleoplasty) Techniques Open a PDF 7.01.62 2023-11-29
Interspinous and Interlaminar Stabilization/Distraction Implants (Spacers) Open a PDF 7.01.75 2023-10-09 Bone & Joints (Orthopedic)
Interfacility Transfer of a Registered Inpatient Open a PDF 11.01.18 2024-04-29 Miscellaneous
Intensity Modulated Radiation Therapy (IMRT) Open a PDF 6.01.24 2024-03-11 Radiation Treatment
Inflammatory Markers of Coronary Artery Disease Risk Open a PDF 2.02.15 2024-05-14 Lab Tests (pathology)
Implantable Cardioverter Defibrillator (ICD) (Effective 2024-08-15) Open a PDF 7.01.06 2024-05-15 Heart & Blood Vessels (Cardiovascular)
Implantable Cardioverter Defibrillator Open a PDF 7.01.06 2023-09-08 Heart & Blood Vessels (Cardiovascular)
Implantable Cardiac Hemodynamic Monitoring for Heart Failure Open a PDF 7.01.91 2023-10-09 Heart & Blood Vessels (Cardiovascular)
Implantable Bone Conduction Hearing Aids Open a PDF 7.01.77 2024-04-29 Ear, Nose & Throat (Otorhinolaryngology)
Immunizations Open a PDF 2.01.42 2024-04-29 Vaccines (Immunizations)
Showing 161– 180 of 307 Results


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