Effective October 1, 2018, updated AmeriHealth Radiation Therapy Clinical Guidelines will be used by CareCore National, LLC d/b/a eviCore healthcare (eviCore).
AmeriHealth delegates precertification of non-emergent outpatient radiation therapy services for all AmeriHealth New Jersey commercial HMO, POS, EPO, and PPO members and AmeriHealth Pennsylvania commercial HMO and POS members to eviCore. eviCore will use the updated Radiation Therapy Clinical Guidelines to determine the medical necessity for these services. For the current guidelines, go to the Resources section of eviCore’s website.
Summary of changes
The following outlines the changes to the Radiation Therapy Clinical Guidelines effective October 1, 2018:
New guidelines:
- Radiation Therapy for Other Cancers
- Radiation Treatment with Lutathera? (Lutetium; Lu 177 dotatate)
Note: Guidelines and utilization management for Lutathera (Lutetium; Lu 177 dotatate) through eviCore became effective July 1, 2018.
Criteria changes:
- Image-Guided Radiation Therapy (IGRT)
- Proton Beam Therapy
- Radiation Therapy for Bladder Cancer
- Radiation Therapy for Bone Metastases
- Radiation Therapy for Brain Metastases
- Radiation Therapy for Breast Cancer
- Radiation Therapy for Cervical Cancer
- Radiation Therapy for Endometrial Cancer
- Radiation Therapy for Esophageal Cancer
- Radiation Therapy for Gastric Cancer
- Radiation Therapy for Head and Neck Cancer
- Radiation Therapy for Lung Cancer
- Radiation Therapy for Non-Malignant Disease
- Radiation Therapy for Oligometastases
- Radiation Therapy for Prostate Cancer
- Radiation Therapy for Skin Cancer
Additional guidelines have been updated and/or revised, but they do not affect the criteria sections.
Policy and guidelines
Medical Policy #09.00.56f: Radiation Therapy Services was posted as a Notification on June 29, 2018, and will go into effect October 1, 2018. The policy includes a link to the Radiation Therapy Clinical Guidelines that eviCore uses, as well as a listing of procedure codes.
To view the Notifications for this policy, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Commercial under Active Notifications.