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 221– 240 of 300 Results
Title Last Updated Category
Artificial Cervical Intervertebral Disc Open a PDF 7.01.80 2023-06-14 Bone & Joints (Orthopedic)
Non-Invasive-Prenatal Testing Open a PDF 2.02.25 2023-06-14 Lab Tests (pathology)
Coverage for Ambulatory Surgery Unit (ASU) and Anesthesia for Dental Services Open a PDF 7.03.01 2023-06-14 Anesthesiology
Artificial Lumbar Intervertebral Disc Open a PDF 7.01.63 2023-06-14 Bone & Joints (Orthopedic)
Osteochondral Grafting of the Knee Open a PDF 7.01.59 2023-06-14 Bone & Joints (Orthopedic)
Autologous Chrondrocyte Implantation Open a PDF 7.01.38 2023-06-14 Bone & Joints (Orthopedic)
MAZE Procedures for Atrial Fibrillation and Flutter Open a PDF 7.01.27 2023-06-14 Heart & Blood Vessels (Cardiovascular)
Bulking Agents for Treatment of Urinary or Fecal Incontinence Open a PDF 7.01.22 2023-06-14 Urinary System (Genitourinary)
Nuclear Breast Imaging Open a PDF 6.01.02 2023-06-14 Radiology (x-rays) & Imaging
Genetic Testing for Cardiac Ion Channelopathies Open a PDF 2.02.38 2023-06-14 Genetic Disease (Inherited Disease)
Bioimpedance Devices for Detection and Management of Lymphedema Open a PDF 2.01.52 2023-06-14 Miscellaneous
Evoked Potentials Open a PDF 2.01.27 2023-06-14 Nervous Systems (Neurology)
Hyperbaric Oxygen Therapy (HBOT) Open a PDF 2.01.07 2023-06-14 Miscellaneous
Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes Open a PDF 1.01.30 2023-06-14 Diabetes (Endocrinology)
Radiofrequency Facet and Sacroiliac Joint Ablation/Denervation Open a PDF 7.01.42 2023-06-14 Bone & Joints (Orthopedic)
Magnetic Esophageal Ring/Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.89 2023-05-15 Digestive System (Gastroenterology)
Interfacility Transfer of a Registered Inpatient Open a PDF 11.01.18 2023-05-12 Miscellaneous
Second Medical and Surgical Opinions Open a PDF 10.01.10 2023-05-12 Miscellaneous
Showing 221– 240 of 300 Results


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