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 21– 40 of 306 Results
Title Last Updated Category
Tibial Nerve Stimulation (TNS) for Voiding Dysfunction Open a PDF 8.01.22 2024-04-29 Nervous Systems (Neurology)
Lung and Lobar Lung Transplant Open a PDF 7.02.10 2024-04-29 Transplants
Responsive Neurostimulation for the Treatment of Refractory Focal Epilepsy Open a PDF 7.01.103 2024-04-29 Nervous Systems (Neurology)
Magnetic Esophageal Ring/Magnetic Sphincter Augmentation for the Treatment of Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.89 2024-04-29 Digestive System (Gastroenterology)
Implantable Bone Conduction Hearing Aids Open a PDF 7.01.77 2024-04-29 Ear, Nose & Throat (Otorhinolaryngology)
Continuing Day Treatment Programs Open a PDF 3.01.20 2024-04-29 Behavioral Health (Psychiatry/Psychology)
Germline Genetic Testing for Hereditary Cancers Open a PDF 2.02.60 2024-04-29 Genetic Disease (Inherited Disease)
Non-Invasive-Prenatal Testing Open a PDF 2.02.25 2024-04-29 Lab Tests (pathology)
Bone Growth Stimulators Open a PDF 1.01.53 2024-04-29 Bone & Joints (Orthopedic)
Vitrectomy Chair/ Face-Down Positioning System Open a PDF 1.01.52 2024-04-29 Durable Medical Equipment & Supplies
Positron Emission Tomography (PET), Oncologic Applications Open a PDF 6.01.29 2024-04-19 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
Showing 21– 40 of 306 Results

 

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