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 261– 280 of 298 Results
Title Last Updated Category
Small Bowel and Multivisceral Transplants in Adults and Children Open a PDF 7.02.05 2024-03-29 Transplants
Speech Pathology and Therapy Open a PDF 8.01.13 2023-09-08 Therapy & Rehabilitation
Spinal Cord Stimulation/Dorsal Column Stimulation Open a PDF 7.01.51 2024-03-14 Bone & Joints (Orthopedic)
Spinal Injections (Epidural and Facet Injections) for Pain Management Open a PDF 7.01.87 2024-03-14 Bone & Joints (Orthopedic)
Spinal Manipulation Under Anesthesia Open a PDF 7.01.76 2024-01-03 Bone & Joints (Orthopedic)
Standing Devices and Gait Trainers Open a PDF 1.01.46 2024-05-13 Durable Medical Equipment & Supplies
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Open a PDF 6.01.12 2024-01-15 Radiation Treatment
Superficial Radiation Therapy for Treatment of Skin Cancers Open a PDF 6.01.43 2023-10-09 Cancer Treatment (Oncology)
Surgical Management of Sleep Disorders (Effective 2024-07-15) Open a PDF 7.01.41 2024-04-15 Sleep Medicine
Surgical Management of Sleep Disorders Open a PDF 7.01.41 2023-04-18 Sleep Medicine
Surgical Stockings and Compression Garments Open a PDF 1.01.14 2024-04-12 Durable Medical Equipment & Supplies
Temporomandibular Joint Disorders (TMJD) Open a PDF 11.01.17 2023-11-29 Bone & Joints (Orthopedic)
Showing 261– 280 of 298 Results


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