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 61– 80 of 306 Results
Title Last Updated Category
Ambulance: Air Open a PDF 11.01.06 2024-03-29 Miscellaneous
Emergency Care Services Open a PDF 10.01.12 2024-03-29 Miscellaneous
Ambulance: Land/Ground Open a PDF 10.01.07 2024-03-29 Miscellaneous
Keratoprosthesis Open a PDF 9.01.15 2024-03-29 Eyes (Ophthalmology)
Ocular Photodynamic Therapy Open a PDF 8.01.11 2024-03-29 Eyes (Ophthalmology)
Ketamine Infusion Therapy for the Treatment of Chronic Pain Syndromes Open a PDF 7.03.03 2024-03-29 Drug / Medications
Small Bowel and Multivisceral Transplants in Adults and Children Open a PDF 7.02.05 2024-03-29 Transplants
Transcatheter Heart Valve Procedures Open a PDF 7.01.109 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Bronchial Thermoplasty Open a PDF 7.01.88 2024-03-29 Lungs (Respiratory)
Extracranial Carotid and Vertebral Artery Angioplasty and Stents Open a PDF 7.01.60 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Blepharoplasty With or Without Levator Muscle Advancement Open a PDF 7.01.55 2024-03-29 Cosmetic / Reconstructive Surgery
Transendoscopic Therapies for Gastroesophageal Reflux Disease (GERD) Open a PDF 7.01.45 2024-03-29 Digestive System (Gastroenterology)
Cochlear Implants and Auditory Brainstem Implants Open a PDF 7.01.26 2024-03-29 Ear, Nose & Throat (Otorhinolaryngology)
Ventricular Assist Devices Open a PDF 7.01.07 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Tumor-Treatment Field Therapy Open a PDF 6.01.45 2024-03-29 Cancer Treatment (Oncology)
JAK2, MPL, and CALR Testing for Myeloproliferative Neoplasms Open a PDF 2.02.53 2024-03-29 Lab Tests (pathology)
Extracorporeal Shock Wave Therapy (ESWT) for Muscoloskeletal Conditions and Soft Tissue Wounds Open a PDF 2.01.31 2024-03-29 Bone & Joints (Orthopedic)
Bioengineered Tissue Products for Wound Treatment and Surgical Interventions Open a PDF 7.01.35 2024-03-29 Skin (Dermatology)
Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers Open a PDF 2.02.51 2024-03-29 Genetic Disease (Inherited Disease)
Orthotics Open a PDF 1.01.25 2024-03-29 Bone & Joints (Orthopedic)
Showing 61– 80 of 306 Results


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