Medical Policies
Access policies for members of other Blue Cross plans
By accessing our medical policies, you signify your agreement to our Terms of Use. Learn more about how medical policies are developedOpen a PDFand about experimental & investigational procedures .
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 |
|---|---|---|
| Vitrectomy Chair/ Face-Down Positioning System Open a PDF 1.01.52 | 2026-04-20 | Durable Medical Equipment & Supplies |
| Wheelchairs and Power Operated Vehicles (POVs) Open a PDF 1.01.16 | 2026-08-25 | Durable Medical Equipment & Supplies |
| Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders Open a PDF 2.02.46 | 2025-09-30 | Genetic Disease (Inherited Disease) |
Modal for Medical Policy and Preauthorization Information for Members of Other BlueCross Plans
Medical Policy and Preauthorization Information for Members of Other BlueCross Plans
If you experience difficulties or need additional information regarding Precertification / Preauthorization, please contact 1-800-676-BLUE (2583).
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Medical Policy Terms of Use
Our Medical Policies contain Physician Current Procedural Terminology ("CPT"), a coding work of nomenclature and five-digit codes for reporting of physician services. CPT is protected by copyright and trademark owned by the American Medical Association ("AMA").
In order to view the item containing CPT you agree:
- AMA is the owner of all copyright, trademark and other rights to CPT and its updates. AMA reserves all such rights. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein.
- CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, implied warranties of merchantability and fitness for a particular use. AMA, Excellus BlueCross BlueShield and its affiliates disclaim any responsibility for any consequences or liability attributable to or related to any use, non-use or interpretation of the information containing CPT.
- Use of CPT by you, your employees, agents and assigns is limited to matters in connection with submitting claims to Excellus BlueCross BlueShield and its affiliates, and only within the United States of America and its territories.
- Any use of CPT not authorized herein in prohibited, including by way of illustration and not by way of limitation, making copies of CPT for sale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, making any commercial use of CPT, or placing CPT or information contained therein in any public electronic bulletin board or public computer based information system (including the Internet and World Wide Web).
- Applicable FARS/DFARS Restrictions apply to Government Use.
- You may make copies of CPT for backup or archival purposes only. Such backup or archival copy must bear notice of the AMA copyright, trademark and proprietary rights to CPT.
- You must take necessary and appropriate action to assure that you, your employees, agents and assigns comply with the terms of this agreement.
- This license shall terminate without notice if you violate its terms.
