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 261– 280 of 287 Results
Title Last Updated Category
Standing Devices and Gait Trainers Open a PDF 1.01.46 2025-02-27 Durable Medical Equipment & Supplies
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Open a PDF 6.01.12 2024-10-30 Radiation Treatment
Surgical Management of Sleep Disorders Open a PDF 7.01.41 2025-05-05 Sleep Medicine
Temporomandibular Joint Disorders (TMJD) Open a PDF 11.01.17 2024-12-04 Bone & Joints (Orthopedic)
Testing for the Use of Biologic Therapeutics for the Treatment of Inflammatory Disorders Open a PDF 2.02.47 2024-12-12 Lab Tests (pathology)
Thermal Ablation for Solid Tumor Treatment Open a PDF 7.01.111 2025-01-09 Cancer Treatment (Oncology)
Tibial Nerve Stimulation (TNS) for Voiding Dysfunction Open a PDF 8.01.22 2025-04-23 Nervous Systems (Neurology)
Total Hip Resurfacing, Metal on Metal Open a PDF 7.01.74 2024-10-02 Bone & Joints (Orthopedic)
Total Parenteral Nutrition (TPN) or Hyperalimentation Open a PDF 11.01.04 2025-02-27 Food (Nutrition)
Transcatheter Heart Valve Procedures Open a PDF 7.01.109 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Transcranial Magnetic Stimulation Open a PDF 3.01.09 2025-01-30 Behavioral Health (Psychiatry/Psychology)
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.45 2025-04-01 Digestive System (Gastroenterology)
Treatment of Gambling Disorder and Other Repetitive Behaviors Open a PDF 3.01.19 2025-02-27 Behavioral Health (Psychiatry/Psychology)
Treatment of Hirsutism/Hypertrichosis (Hair Removal) Open a PDF 2.01.38 2024-12-30 Cosmetic / Reconstructive Surgery
Showing 261– 280 of 287 Results

 

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