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 121– 140 of 305 Results
Title Last Updated Category
Hip Arthroplasty Open a PDF 7.01.96 2023-05-12 Bone & Joints (Orthopedic)
Home Automatic External Defibrillators (AEDs) and Wearable Cardioverter Defibrillators (WCDs) Open a PDF 1.01.42 2023-07-13 Heart & Blood Vessels (Cardiovascular)
Home Birth by Certified Nurse Midwives Open a PDF 11.01.23 2023-11-02 Women's Health (Obstetrics & Gynecology)
Home Phototherapy for Hyperbilirubinemia Open a PDF 1.01.33 2023-09-08 Children's Health (Pediatrics)
Home Prothrombin Time Monitor Device Open a PDF 1.01.44 2023-07-18 Home Care
Hyperbaric Oxygen Therapy (HBOT) Open a PDF 2.01.07 2024-05-30 Miscellaneous
Immunizations Open a PDF 2.01.42 2024-04-29 Vaccines (Immunizations)
Implantable Bone Conduction Hearing Aids Open a PDF 7.01.77 2024-04-29 Ear, Nose & Throat (Otorhinolaryngology)
Implantable Cardiac Hemodynamic Monitoring for Heart Failure Open a PDF 7.01.91 2023-10-09 Heart & Blood Vessels (Cardiovascular)
Implantable Cardioverter Defibrillator Open a PDF 7.01.06 2023-09-08 Heart & Blood Vessels (Cardiovascular)
Implantable Cardioverter Defibrillator (ICD) (Effective 2024-08-15) Open a PDF 7.01.06 2024-05-15 Heart & Blood Vessels (Cardiovascular)
Inflammatory Markers of Coronary Artery Disease Risk Open a PDF 2.02.15 2024-05-14 Lab Tests (pathology)
Intensity Modulated Radiation Therapy (IMRT) Open a PDF 6.01.24 2024-03-11 Radiation Treatment
Interfacility Transfer of a Registered Inpatient Open a PDF 11.01.18 2024-04-29 Miscellaneous
Interspinous and Interlaminar Stabilization/Distraction Implants (Spacers) Open a PDF 7.01.75 2023-10-09 Bone & Joints (Orthopedic)
Intervertebral Disc Decompression Laser (Laser Discectomy) and Radiofrequency Coblation (Disc Nucleoplasty™) Techniques Open a PDF 7.01.62 2023-11-29 Bone & Joints (Orthopedic)
Intraocular Lens (IOL) Implants Open a PDF 9.01.14 2023-11-02 Eyes (Ophthalmology)
Intravascular Ultrasound (IVUS) Open a PDF 6.01.09 2023-08-09 Heart & Blood Vessels (Cardiovascular)
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms Open a PDF 2.02.53 2024-03-29 Lab Tests (pathology)
Showing 121– 140 of 305 Results


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