As previously communicated in a Partners in Health UpdateSM article, as of July 1, 2019, CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company, is using updated Radiation Therapy Clinical Guidelines for Independence members.
Independence has delegated the responsibility for utilization management activities for certain radiation therapy services to eviCore for all Independence commercial HMO, POS, EPO, and PPO members and Medicare Advantage Independence HMO, POS, and PPO members. eviCore uses the Radiation Therapy Clinical Guidelines to determine the medical necessity for these services.
To access the guidelines, go to the Radiation Oncology section of eviCore’s website, type Independence Blue Cross in the Search field, and then choose Current to view the Radiation Therapy Clinical Guidelines.
Summary changes
The following outlines changes to the Radiation Therapy Clinical Guidelines effective as of July 1, 2019:
There are two new guidelines and ten revised guidelines with changes in the criteria sections. Additional guidelines have been updated and/or revised, but these changes do not affect the criteria sections.
New guidelines:
- Radiation Therapy for Non-Small Cell Lung Cancer
- Radiation Therapy for Small Cell Lung Cancer
In previous versions, the two new guidelines were combined into one guideline titled “Radiation Therapy for Lung Cancer.”
Criteria changes:
- Proton Beam Therapy
- Radiation Therapy for Breast Cancer
- Radiation Therapy for Non-Malignant Disorders
- Radiation Therapy for Non-Small Cell Lung Cancer – This is a new guideline that was part of the Radiation Therapy for Lung Cancer guideline.
- Radiation Therapy for Oligometastases
- Radiation Therapy for Primary Craniospinal Tumors and Neurologic Conditions
- Radiation Therapy for Prostate Cancer
- Radiation Therapy for Small Cell Lung Cancer – This is a new guideline that was part of the Radiation Therapy for Lung Cancer guideline.
- Radiation Therapy for Urethral Cancer and Upper Genitourinary Tract Tumors
- Radiation Treatment with Lutathera (Lutetium; Lu 177 dotatate)
Policies and guidelines
The following policies, which include a link to the Radiation Therapy Clinical Guidelines that eviCore uses and a list of procedure codes, were posted as Notifications on April 1, 2019, and are effective as of July 1, 2019:
- Commercial: #09.00.56i: Radiation Therapy Services
- Medicare Advantage: #MA09.020i: Radiation Therapy Services
To view these policies, visit our Medical Policy Portal.