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 21– 40 of 301 Results
Title Last Updated Category
Transcranial Magnetic Stimulation Open a PDF 3.01.09 2024-03-11 Behavioral Health (Psychiatry/Psychology)
Transcatheter Heart Valve Procedures Open a PDF 7.01.109 2024-03-29 Heart & Blood Vessels (Cardiovascular)
Transcatheter Closure Devices for Cardiac Defects and Patent Ductus Arteriosus Open a PDF 7.01.34 2023-08-09 Heart & Blood Vessels (Cardiovascular)
Total Parenteral Nutrition (TPN) or Hyperalimentation Open a PDF 11.01.04 2024-03-04 Food (Nutrition)
Total Hip Resurfacing, Metal on Metal Open a PDF 7.01.74 2023-05-12 Bone & Joints (Orthopedic)
Tibial Nerve Stimulation (TNS) for Voiding Dysfunction Open a PDF 8.01.22 2024-04-29 Nervous Systems (Neurology)
Temporomandibular Joint Disorders (TMJD) Open a PDF 11.01.17 2023-11-29 Bone & Joints (Orthopedic)
Surgical Stockings and Compression Garments Open a PDF 1.01.14 2024-04-12 Durable Medical Equipment & Supplies
Surgical Management of Sleep Disorders (Effective 2024-07-15) Open a PDF 7.01.41 2024-04-15 Sleep Medicine
Surgical Management of Sleep Disorders Open a PDF 7.01.41 2023-04-18 Sleep Medicine
Superficial Radiation Therapy for Treatment of Skin Cancers Open a PDF 6.01.43 2023-10-09 Cancer Treatment (Oncology)
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Open a PDF 6.01.12 2024-01-15 Radiation Treatment
Standing Devices and Gait Trainers Open a PDF 1.01.46 2024-05-13 Durable Medical Equipment & Supplies
Spinal Manipulation Under Anesthesia Open a PDF 7.01.76 2024-01-03 Bone & Joints (Orthopedic)
Spinal Injections (Epidural and Facet Injections) for Pain Management Open a PDF 7.01.87 2024-03-14 Bone & Joints (Orthopedic)
Showing 21– 40 of 301 Results


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