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 261– 280 of 305 Results
Title Last Updated Category
Balloon Dilation of the Eustachian Tube Open a PDF 7.01.101 2024-09-04 Ear, Nose & Throat (Otorhinolaryngology)
Balloon Sinus Ostial Dilation for Treatment of Chronic Rhinosinusitis (i.e., Balloon Sinuplasty) Open a PDF 7.01.85 2024-09-04 Ear, Nose & Throat (Otorhinolaryngology)
Focal Therapies for Prostate Cancer Treatment Open a PDF 7.01.01 2024-09-04 Urinary System (Genitourinary)
Proton Beam Radiation Therapy Open a PDF 6.01.11 2024-09-04 Radiation Treatment
Bone Densitometry/Bone Density Studies Open a PDF 6.01.05 2024-09-04 Radiology (x-rays) & Imaging
Partial Hospitalization for Substance Use Disorders Open a PDF 3.01.18 2024-09-04 Behavioral Health (Psychiatry/Psychology)
Behavioral Health Treatment for Gender Dysphoria Open a PDF 3.01.15 2024-09-04 Behavioral Health (Psychiatry/Psychology)
Computerized Motion Diagnostic Imaging (CMDI)/Gait Analysis Open a PDF 2.01.13 2024-09-04 Bone & Joints (Orthopedic)
Functional Electrical Stimulation (FES) and Neuromuscular Electrical Stimulation (NMES) Open a PDF 1.01.48 2024-09-04 Durable Medical Equipment & Supplies
Wheelchairs and Power Operated Vehicles Open a PDF 1.01.16 2024-09-04 Durable Medical Equipment & Supplies
Surgical Stockings and Compression Garments Open a PDF 1.01.14 2024-09-04 Durable Medical Equipment & Supplies
Oral Appliance for the Treatment of Obstructive Sleep Apnea Open a PDF 1.01.07 2024-09-04 Lungs (Respiratory)
Augmentative and Alternative Communication Systems (e.g., Speech-generating Devices) Open a PDF 1.01.03 2024-09-04 Durable Medical Equipment & Supplies
Durable Medical Equipment Standard and Non-Standard Open a PDF 1.01.00 2024-09-04 Durable Medical Equipment & Supplies
Ablation/Denervation Techniques for Knee Pain Open a PDF 7.01.100 2024-09-12 Bone & Joints (Orthopedic)
Angioplasty and Stenting of Extracranial, Intracranial and Vertebral Arteries (Effective 2024-12-16) Open a PDF 7.01.110 2024-09-16 Nervous Systems (Neurology)
Immunizations Open a PDF 2.01.42 2024-09-19 Vaccines (Immunizations)
Radiopharmaceuticals for the Treatment of Cancer Open a PDF 6.01.44 2024-09-24 Cancer Treatment (Oncology)
Clinical Trials Open a PDF 11.01.10 2024-09-24 Miscellaneous
Implantable Cardiac Hemodynamic Monitoring for Heart Failure Open a PDF 7.01.91 2024-09-24 Heart & Blood Vessels (Cardiovascular)
Showing 261– 280 of 305 Results

 

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