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 221– 240 of 288 Results
Title Last Updated Category
Positron Emission Tomography (PET) Oncologic Applications Open a PDF 6.01.29 2024-12-17 Radiology (x-rays) & Imaging
Positron Emission Tomography (PET)- Non-Oncologic Applications Open a PDF 6.01.07 2024-12-30 Radiology (x-rays) & Imaging
Powered Compression Devices/Lymphedema Pumps Open a PDF 1.01.17 2024-12-30 Durable Medical Equipment & Supplies
Predictive Testing for Pancreatic Cancer Open a PDF 2.02.39 2025-06-20 Lab Tests (pathology)
Prenatal Genetic Testing Open a PDF 4.01.03 2024-12-04 Genetic Disease (Inherited Disease)
Private Rooms Open a PDF 12.01.06 2024-12-04 Miscellaneous
Prolotherapy Open a PDF 8.01.10 2024-12-30 Bone & Joints (Orthopedic)
Proton Beam Radiation Therapy Open a PDF 6.01.11 2024-09-04 Radiation Treatment
Psychological Testing Open a PDF 3.01.02 2024-12-30 Behavioral Health (Psychiatry/Psychology)
Radioembolization (TARE) for Hepatic Tumors Open a PDF 7.01.69 2025-02-27 Radiation Treatment
Radiofrequency Facet and Sacroiliac Joint Ablation/Denervation Open a PDF 7.01.42 2024-11-01 Bone & Joints (Orthopedic)
Radiopharmaceuticals for the Treatment of Cancer Open a PDF 6.01.44 2025-04-01 Cancer Treatment (Oncology)
Reduction Mammaplasty (Mammoplasty) Open a PDF 7.01.39 2025-01-29 Cosmetic / Reconstructive Surgery
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy Open a PDF 7.01.103 2025-05-30 Nervous Systems (Neurology)
Showing 221– 240 of 288 Results

 

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