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 21– 40 of 303 Results
Title Last Updated Category
Artificial Hearts Open a PDF 7.01.65 2023-07-18 Heart & Blood Vessels (Cardiovascular)
Artificial Lumbar Intervertebral Disc Open a PDF 7.01.63 2023-06-14 Bone & Joints (Orthopedic)
Assisted Reproductive Technologies – In Vitro Fertilization Open a PDF 4.01.05 2024-01-03 Women's Health (Obstetrics & Gynecology)
Augmentative and Alternative Communication Systems (e.g., Speech-generating Devices) Open a PDF 1.01.03 2023-12-21 Durable Medical Equipment & Supplies
Autologous Chrondrocyte Implantation Open a PDF 7.01.38 2023-06-14 Bone & Joints (Orthopedic)
Autologous Hematopoietic Stem Cell Transplantation Open a PDF 7.02.03 2024-01-03 Transplants
Automated Percutaneous Discectomy and Image-Guided, Minimally Invasive Decompression Open a PDF 7.01.16 2023-07-18 Bone & Joints (Orthopedic)
Balloon Dilation of the Eustachian Tube Open a PDF 7.01.101 2023-10-09 Ear, Nose & Throat (Otorhinolaryngology)
Balloon Sinus Ostial Dilation for Treatment of Chronic Rhinosinusitis (i.e., Balloon Sinuplasty) Open a PDF 7.01.85 2023-09-15 Ear, Nose & Throat (Otorhinolaryngology)
Bariatric and Metabolic Surgery Open a PDF 7.01.29 2024-05-30 Digestive System (Gastroenterology)
Behavioral Health Treatment for Gender Dysphoria Open a PDF 3.01.15 2023-08-09 Behavioral Health (Psychiatry/Psychology)
Biochemical Markers of Bone Turnover Open a PDF 2.02.18 2023-08-09 Lab Tests (pathology)
Bioengineered Tissue Products for Wound Treatment and Surgical Interventions Open a PDF 7.01.35 2024-03-29 Skin (Dermatology)
Biofeedback Open a PDF 2.01.09 2023-07-18 Alternative Medicine
Bioimpedance Devices for Detection and Management of Lymphedema Open a PDF 2.01.52 2024-05-30 Miscellaneous
Blepharoplasty With or Without Levator Muscle Advancement Open a PDF 7.01.55 2024-03-29 Cosmetic / Reconstructive Surgery
Bone Densitometry/Bone Density Studies Open a PDF 6.01.05 2023-09-08 Radiology (x-rays) & Imaging
Showing 21– 40 of 303 Results

 

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