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 41– 60 of 302 Results
Title Last Updated Category
Bone Densitometry/Bone Density Studies Open a PDF 6.01.05 2023-09-08 Radiology (x-rays) & Imaging
Bone Growth Stimulators Open a PDF 1.01.53 2024-04-29 Bone & Joints (Orthopedic)
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
Brachytherapy or Radioactive Seed Implantation for Prostate Cancer Open a PDF 6.01.16 2023-11-29 Radiation Treatment
Breast Reconstruction Surgery Open a PDF 10.01.01 2023-09-08 Cosmetic / Reconstructive Surgery
Bronchial Thermoplasty Open a PDF 7.01.88 2024-03-29 Lungs (Respiratory)
Bulking Agents for Treatment of Urinary or Fecal Incontinence Open a PDF 7.01.22 2024-05-30 Urinary System (Genitourinary)
Cardiac Rehabilitation Open a PDF 8.01.14 2023-11-02 Therapy & Rehabilitation
Cardiac Resynchronization Therapy (Biventricular Pacemakers) for the Treatment of Heart Failure Open a PDF 7.01.58 2023-09-08 Heart & Blood Vessels (Cardiovascular)
Cardiac/Coronary Computed Tomographic Angiography (Cardiac/Coronary CTA): Contrast-Enhanced Open a PDF 6.01.34 2024-01-15 Radiology (x-rays) & Imaging
Chelation Therapy Open a PDF 8.01.03 2023-11-02 Blood Disorders (Hematology)
Chiropractic Care Open a PDF 10.01.02 2023-08-09 Chiropractic
Chromosomal Microarray (CMA) Analysis for Prenatal Evaluation and Evaluation of Patients with Developmental Delay/ Intellectual Disability or Autism Spectrum Disorder Open a PDF 2.02.42 2024-01-03 Genetic Disease (Inherited Disease)
Circulating Tumor DNA for Management of Cancer (Liquid Biopsy) Open a PDF 2.02.56 2024-02-09 Lab Tests (pathology)
Clinical Trials Open a PDF 11.01.10 2024-06-27 Miscellaneous
Cochlear Implants and Auditory Brainstem Implants Open a PDF 7.01.26 2024-03-29 Ear, Nose & Throat (Otorhinolaryngology)
Cognitive Rehabilitation Open a PDF 8.01.19 2023-11-02 Therapy & Rehabilitation
Showing 41– 60 of 302 Results


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