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 41– 60 of 304 Results
Title Last Updated Category
Alopecia (Hair Loss) Open a PDF 2.01.36 2024-12-30 Cosmetic / Reconstructive Surgery
Powered Compression Devices/Lymphedema Pumps Open a PDF 1.01.17 2024-12-30 Durable Medical Equipment & Supplies
Optical Coherence Tomography for Ophthalmological Applications (OCT) Open a PDF 9.01.10 2024-12-30 Eyes (Ophthalmology)
Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers Open a PDF 2.02.51 2024-12-30 Genetic Disease (Inherited Disease)
Dynamic Adjustable Braces Open a PDF 1.01.35 2024-12-30 Bone & Joints (Orthopedic)
Circulating Tumor DNA for Management of Cancer (Liquid Biopsy) Open a PDF 2.02.56 2024-12-30 Lab Tests (pathology)
Bioengineered Tissue Products for Wound Treatment and Surgical Interventions Open a PDF 7.01.35 2024-12-30 Skin (Dermatology)
Angioplasty and Stenting of Extracranial, Intracranial and Vertebral Arteries Open a PDF 7.01.110 2024-12-26 Nervous Systems (Neurology)
Selective Internal Radiation Therapy (SIRT) for Hepatic Tumors Open a PDF 7.01.69 2024-12-23 Radiation Treatment
Dental Implants Open a PDF 13.01.01 2024-12-17 Dental
Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (Effective 2025-03-17) Open a PDF 6.01.34 2024-12-17 Radiology (x-rays) & Imaging
Positron Emission Tomography (PET) Oncologic Applications (Effective 2025-03-17) Open a PDF 6.01.29 2024-12-17 Radiology (x-rays) & Imaging
New/Emerging Technology & Services (Effective 2025-03-17) Open a PDF 11.01.27 2024-12-17 Miscellaneous
Continuous Glucose Monitoring Systems/External Insulin Pump Therapy for Diabetes Open a PDF 1.01.30 2024-12-13 Diabetes (Endocrinology)
Testing for the Use of Biologic Therapeutics for the Treatment of Inflammatory Disorders Open a PDF 2.02.47 2024-12-12 Lab Tests (pathology)
Brachytherapy After Breast-Conserving Surgery, as Boost with Whole Breast Irradiation or Alone as Accelerated Partial Breast Irradiation Open a PDF 6.01.30 2024-12-04 Radiation Treatment
Private Rooms Open a PDF 12.01.06 2024-12-04 Miscellaneous
Temporomandibular Joint Disorders (TMJD) Open a PDF 11.01.17 2024-12-04 Bone & Joints (Orthopedic)
Coverage for Dependents with Disabilities Open a PDF 10.01.08 2024-12-04 Miscellaneous
Vision Therapy Open a PDF 9.01.04 2024-12-04 Eyes (Ophthalmology)
Showing 41– 60 of 304 Results

 

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