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 301– 304 of 304 Results
Title Last Updated Category
Vitrectomy Chair/ Face-Down Positioning System Open a PDF 1.01.52 2024-04-29 Durable Medical Equipment & Supplies
Wheelchairs and Power Operated Vehicles Open a PDF 1.01.16 2024-03-28 Durable Medical Equipment & Supplies
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Open a PDF 2.02.46 2023-12-27 Genetic Disease (Inherited Disease)
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders Open a PDF 6.01.27 2023-11-15 Digestive System (Gastroenterology)
Showing 301– 304 of 304 Results

 

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