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 1– 20 of 293 Results
Title Last Updated Category
Surgical Management of Sleep Disorders Open a PDF 7.01.41 2025-05-05 Sleep Medicine
Tibial Nerve Stimulation (TNS) for Voiding Dysfunction Open a PDF 8.01.22 2025-04-23 Nervous Systems (Neurology)
Kidney Transplantation Open a PDF 7.02.04 2025-04-23 Transplants
Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.89 2025-04-23 Digestive System (Gastroenterology)
Implantable Bone Conduction Hearing Aids Open a PDF 7.01.77 2025-04-23 Ear, Nose & Throat (Otorhinolaryngology)
Deep Brain Stimulation Open a PDF 7.01.23 2025-04-23 Nervous Systems (Neurology)
Bulking Agents for Treatment of Urinary or Fecal Incontinence Open a PDF 7.01.22 2025-04-23 Urinary System (Genitourinary)
Continuing Day Treatment Programs Open a PDF 3.01.20 2025-04-23 Behavioral Health (Psychiatry/Psychology)
Genetic Assay of Tumor Tissue to Determine Prognosis and Treatment of Breast Cancer Open a PDF 2.02.27 2025-04-23 Genetic Disease (Inherited Disease)
Non-Invasive-Prenatal Testing Open a PDF 2.02.25 2025-04-23 Lab Tests (pathology)
Second Medical and Surgical Opinions Open a PDF 10.01.10 2025-04-23 Miscellaneous
Bone Growth Stimulators Open a PDF 1.01.53 2025-04-23 Bone & Joints (Orthopedic)
Vitrectomy Chair/ Face-Down Positioning System Open a PDF 1.01.52 2025-04-23 Durable Medical Equipment & Supplies
Pelvic Floor Electrical Stimulation as a Treatment for Urinary or Fecal Incontinence Open a PDF 1.01.19 2025-04-23 Urinary System (Genitourinary)
Germline Genetic Testing for Hereditary Cancers Open a PDF 2.02.60 2025-04-22 Genetic Disease (Inherited Disease)
Lumbar Decompression Open a PDF 7.01.113 2025-04-17 Bone & Joints (Orthopedic)
Lumbar Microdiscectomy Open a PDF 7.01.98 2025-04-17 Bone & Joints (Orthopedic)
Artificial Cervical Intervertebral Disc Open a PDF 7.01.80 2025-04-17 Bone & Joints (Orthopedic)
Artificial Lumbar Intervertebral Disc Open a PDF 7.01.63 2025-04-17 Bone & Joints (Orthopedic)
Percutaneous Vertebroplasty/Mechanical Vertebral Augmentation and Percutaneous Sacroplasty Open a PDF 6.01.17 2025-04-17 Bone & Joints (Orthopedic)
Showing 1– 20 of 293 Results

 

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