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 1– 20 of 302 Results
Title Last Updated Category
Positron Emission Tomography (PET), Oncologic Applications Open a PDF 6.01.29 2024-04-15 Radiology (x-rays) & Imaging
CT (Computed Tomography) Perfusion Imaging of the Brain Open a PDF 6.01.37 2024-04-15 Radiology (x-rays) & Imaging
Magnetic Resonance Imaging‒Prostate/Multiparametric MRI Open a PDF 6.01.46 2024-04-15 Radiology (x-rays) & Imaging
Low-Dose Computed Tomography (LDCT) for Lung Cancer Screening Open a PDF 6.01.19 2024-04-15 Radiology (x-rays) & Imaging
Magnetic Resonance Spectroscopy (MRS) Open a PDF 6.01.03 2024-04-15 Radiology (x-rays) & Imaging
Surgical Management of Sleep Disorders (Effective 2024-07-15) Open a PDF 7.01.41 2024-04-15 Sleep Medicine
Pancreas Transplant: (Pancreas Transplant Alone, Pancreas Transplant after Kidney Transplant, Simultaneous Pancreas Kidney Transplant): Islet Cell Transplant (Effective 2024-07-15) Open a PDF 7.02.01 2024-04-15 Transplants
Genetic Assay of Tumor Tissue to Determine Prognosis and Treatment of Breast Cancer (Effective 2024-07-15) Open a PDF 2.02.27 2024-04-15 Genetic Disease (Inherited Disease)
Transcutaneous and Percutaneous Nerve Stimulation as a Treatment for Pain and Other Conditions (Effective 2024-07-15) Open a PDF 1.01.01 2024-04-15 Durable Medical Equipment & Supplies
Surgical Stockings and Compression Garments Open a PDF 1.01.14 2024-04-12 Durable Medical Equipment & Supplies
Lumbar Decompression Open a PDF 7.01.97 2024-04-12 Bone & Joints (Orthopedic)
Cryosurgical Tumor Ablation Open a PDF 7.01.03 2024-04-05 Cancer Treatment (Oncology)
Ambulance: Air Open a PDF 11.01.06 2024-03-29 Miscellaneous
Emergency Care Services Open a PDF 10.01.12 2024-03-29 Miscellaneous
Ambulance: Land/Ground Open a PDF 10.01.07 2024-03-29 Miscellaneous
Keratoprosthesis Open a PDF 9.01.15 2024-03-29 Eyes (Ophthalmology)
Ocular Photodynamic Therapy Open a PDF 8.01.11 2024-03-29 Eyes (Ophthalmology)
Ketamine Infusion Therapy for the Treatment of Chronic Pain Syndromes Open a PDF 7.03.03 2024-03-29 Drug / Medications
Small Bowel and Multivisceral Transplants in Adults and Children Open a PDF 7.02.05 2024-03-29 Transplants
Transcatheter Heart Valve Procedures Open a PDF 7.01.109 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Showing 1– 20 of 302 Results


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