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 306 Results
Title Last Updated Category
Experimental or Investigational Services Open a PDF 11.01.03 2024-05-29 Miscellaneous
Positron Emission Tomography (PET) - Non-Oncologic Applications (Effective 2024-08-15) Open a PDF 6.01.07 2024-05-15 Radiology (x-rays) & Imaging
Kidney Transplantation (Effective 2024-08-15) Open a PDF 7.02.04 2024-05-15 Transplants
Pacemakers and Cardiac Resynchronization Therapy (CRT) Devices (Effective 2024-08-15) Open a PDF 7.01.58 2024-05-15 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)
Cranial Orthotics (Effective 2024-08-15) Open a PDF 1.01.32 2024-05-15 Children's Health (Pediatrics)
Inflammatory Markers of Coronary Artery Disease Risk Open a PDF 2.02.15 2024-05-14 Lab Tests (pathology)
Colorectal Cancer Screening and Surveillance Open a PDF 2.01.51 2024-05-14 Digestive System (Gastroenterology)
Measurement of Serum Antibodies to Tumor Necrosis Factor Blockers Open a PDF 2.02.47 2024-05-14 Lab Tests (pathology)
Pharmacogenetics Open a PDF 2.02.30 2024-05-14 Genetic Disease (Inherited Disease)
Urinary Tumor Markers for Bladder Cancer Open a PDF 2.02.12 2024-05-14 Lab Tests (pathology)
Standing Devices and Gait Trainers (Effective 2024-06-14) Open a PDF 1.01.46 2024-05-13 Durable Medical Equipment & Supplies
Standing Devices and Gait Trainers Open a PDF 1.01.46 2024-05-13 Durable Medical Equipment & Supplies
Acupuncture and Auricular Electrostimulation Open a PDF 8.01.20 2024-05-02 Alternative Medicine
Deep Brain Stimulation Open a PDF 7.01.23 2024-05-02 Nervous Systems (Neurology)
Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors Open a PDF 7.01.69 2024-04-30 Radiation Treatment
Immunizations Open a PDF 2.01.42 2024-04-29 Vaccines (Immunizations)
Interfacility Transfer of a Registered Inpatient Open a PDF 11.01.18 2024-04-29 Miscellaneous
Second Medical and Surgical Opinions Open a PDF 10.01.10 2024-04-29 Miscellaneous
Optical Coherence Tomography for Ophthalmological Applications (OCT) Open a PDF 9.01.10 2024-04-29 Eyes (Ophthalmology)
Showing 1– 20 of 306 Results


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