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 241– 260 of 298 Results
Title Last Updated Category
Allergy Testing Open a PDF 2.01.10 2023-07-13 Ear, Nose & Throat (Otorhinolaryngology)
Home Automatic External Defibrillators (AEDs) and Wearable Cardioverter Defibrillators (WCDs) Open a PDF 1.01.42 2023-07-13 Heart & Blood Vessels (Cardiovascular)
Applied Behavior Analysis Open a PDF 3.01.11 2023-06-30 Behavioral Health (Psychiatry/Psychology)
Artificial Cervical Intervertebral Disc Open a PDF 7.01.80 2023-06-14 Bone & Joints (Orthopedic)
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)
Radiofrequency Facet and Sacroiliac Joint Ablation/Denervation Open a PDF 7.01.42 2023-06-14 Bone & Joints (Orthopedic)
Hip Arthroplasty Open a PDF 7.01.96 2023-05-12 Bone & Joints (Orthopedic)
Total Hip Resurfacing, Metal on Metal Open a PDF 7.01.74 2023-05-12 Bone & Joints (Orthopedic)
Abdominoplasty and Panniculectomy Open a PDF 7.01.53 2023-05-12 Cosmetic / Reconstructive Surgery
Surgical Management of Sleep Disorders Open a PDF 7.01.41 2023-04-18 Sleep Medicine
Showing 241– 260 of 298 Results


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