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.
To view drug policies, guidelines and supporting documentation, please visit our View Drug Policies page.
| Title | Last Updated | Category |
|---|---|---|
| Tibial Nerve Stimulation (TNS) for Voiding Dysfunction Open a PDF 8.01.22 | 2025-04-23 | Nervous Systems (Neurology) |
| Thermal Ablation for Solid Tumor Treatment Open a PDF 7.01.111 | 2025-08-28 | Cancer Treatment (Oncology) |
| 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) |
| Temporomandibular Joint Disorders (TMJD) Open a PDF 11.01.17 | 2025-09-19 | Bone & Joints (Orthopedic) |
| Surgical Management of Sleep Disorders (Effective 2025-12-15) Open a PDF 7.01.41 | 2025-09-15 | Sleep Medicine |
| Surgical Management of Sleep Disorders Open a PDF 7.01.41 | 2025-05-05 | Sleep Medicine |
| Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Open a PDF 6.01.12 | 2025-11-14 | Radiation Treatment |
| Standing Devices and Gait Trainers Open a PDF 1.01.46 | 2025-02-27 | Durable Medical Equipment & Supplies |
