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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| Title | Last Updated | Category |
|---|---|---|
| Brachytherapy After Breast-Conserving Surgery, as Boost with Whole Breast Irradiation or Alone as Accelerated Partial Breast Irradiation Open a PDF 6.01.30 | 2023-02-15 | Radiation Treatment |
| Gender Reassignment/Gender Affirming Surgery and Treatments for Medicaid Managed Care Plan (MMCP) and Health and Recovery Plan (HARP) Members Open a PDF 7.01.105 | 2023-02-15 | Miscellaneous |
| Gender Affirming Surgery and Treatments for Commercial and Medicare Advantage Members Open a PDF 7.01.84 | 2023-03-07 | Miscellaneous |
| Abdominoplasty and Panniculectomy Open a PDF 7.01.53 | 2023-05-12 | Cosmetic / Reconstructive Surgery |
| Hip Arthroplasty Open a PDF 7.01.96 | 2023-05-12 | Bone & Joints (Orthopedic) |
| 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) |
