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.
| Title | Last Updated | Category |
|---|---|---|
| Sinus Excision/Destruction, Implants, and Repair Open a PDF 7.01.99 | 2025-12-23 | Ear, Nose & Throat (Otorhinolaryngology) |
| Skilled Nursing Facility Care / Level of Care Criteria Open a PDF 11.01.21 | 2025-07-24 | Miscellaneous |
| Sleep Studies Open a PDF 2.01.28 | 2026-01-27 | Sleep Medicine |
| Small Bowel and Multivisceral Transplants in Adults and Children Open a PDF 7.02.05 | 2026-03-24 | Transplants |
| Specialty Enclosure Bed Systems Open a PDF 1.01.56 | 2026-02-13 | Durable Medical Equipment & Supplies |
| Spinal Cord Stimulation / Dorsal Column Stimulation Open a PDF 7.01.51 | 2025-07-11 | Bone & Joints (Orthopedic) |
| Standing Devices and Gait Trainers Open a PDF 1.01.46 | 2026-02-23 | Durable Medical Equipment & Supplies |
