Gastroenterology
Please note:
Adobe PDF Reader is required to view clinical guideline documents.
There may be instances in which your health plan policies take precedence over the EviCore by Evernorth clinical guidelines. If you have any questions, please reach out to your health plan.
If you would like to view all EviCore core guidelines, please type in "EviCore by Evernorth" as your health plan.
To access the clinical guidelines:
- Enter your Health Plan name into the search field and click on the magnifying glass.
- To access the guideline specific to your request, locate the “reason for denial” section found in your letter.
- Identify the guideline title and then search for that guideline title by scrolling down on the page or entering the guideline title into the guideline name search field.
- Open that guideline, and scroll to the table of contents.
- Click on the section mentioned in your letter.
If you require a copy of the guidelines that were used to make a determination on a specific request of treatment or services, please email the case number and request to: reqcriteria@EviCore.com.
To request any additional assistance in accessing the guidelines, provide feedback or clinical evidence related to the evidence-based guidelines, please click here.
EviCore coverage policies include background and supporting information and citations for sources used to develop the policy. Some clinical policies may have a supplemental literature summary available which will provide additional commentary regarding clinical benefits and harms to the patient population being served. Additional literature summaries may be accessed by selecting ‘Supplemental Information’ and then entering “EviCore by Evernorth” in the search by health plan function.
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Clinical Information to Determine Medical NecessityEffective 07/15/2021 - 02/14/2023
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Clinical Information to Determine Medical NecessityEffective 02/15/2023 - 04/02/2023
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Clinical Information to Determine Medical NecessityEffective 06/01/2021 - 07/14/2021
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Preface to the Imaging GuidelinesEffective 01/01/2022 - 02/28/2022
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Preface to the Imaging GuidelinesEffective 11/01/2023 - 01/31/2024
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Preface to the Imaging GuidelinesEffective 02/01/2024 - 03/31/2024
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Preface to the Imaging GuidelinesEffective 03/01/2022 - 09/30/2022
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Preface to the Imaging GuidelinesEffective 10/01/2022 - 02/14/2023
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Preface to the Imaging GuidelinesEffective 09/01/2021 - 12/31/2021
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Preface to the Imaging GuidelinesEffective 06/01/2021 - 08/31/2021
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Preface to the Imaging GuidelinesEffective 02/15/2023 - 04/09/2023
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Capsule Endoscopy GuidelinesEffective 07/01/2021 - 02/28/2022
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Capsule Endoscopy GuidelinesEffective 05/01/2025 - 06/30/2025
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Capsule Endoscopy GuidelinesEffective 06/01/2021 - 06/30/2021
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Capsule Endoscopy GuidelinesEffective 05/15/2023 - 02/29/2024
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Capsule Endoscopy GuidelinesEffective 03/01/2022 - 05/14/2023
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Capsule Endoscopy GuidelinesEffective 03/01/2024 - 04/30/2025
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Colonoscopy GuidelinesEffective 01/01/2022 - 05/14/2023
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Colonoscopy GuidelinesEffective 08/01/2024 - 04/30/2025
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Colonoscopy GuidelinesEffective 05/15/2023 - 02/29/2024
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Colonoscopy GuidelinesEffective 06/01/2021 - 06/30/2021
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Colonoscopy GuidelinesEffective 07/01/2021 - 12/31/2021
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Colonoscopy GuidelinesEffective 03/01/2024 - 07/31/2024
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Esophagogastroduodenoscopy (EGD) GuidelinesEffective 11/01/2022 - 05/14/2023
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Esophagogastroduodenoscopy (EGD) GuidelinesEffective 03/01/2024 - 04/30/2025
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Esophagogastroduodenoscopy (EGD) GuidelinesEffective 09/01/2023 - 02/29/2024
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Esophagogastroduodenoscopy (EGD) GuidelinesEffective 05/15/2023 - 08/31/2023
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Esophagogastroduodenoscopy (EGD) GuidelinesEffective 06/01/2021 - 02/28/2022
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Esophagogastroduodenoscopy (EGD) GuidelinesEffective 03/01/2022 - 10/31/2022
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Screening Colonoscopy GuidelinesEffective 05/01/2025 - 05/30/2025