​​​​​​​​​​​Now in ef​fect! Updated R​adiation Therapy Clinical Guidelines​​

October 1, 2020

As of October 1, 2020, eviCore healthcare (eviCore), an independent specialty benefit management company, has updated its Radiation Therapy Clinical Guidelines for Independence members.

Independence has delegated the responsibility for utilization management activities for certain radiation therapy services to eviCore for commercial Independence members. eviCore is now using the updated Radiation Therapy Clinical Guidelines to determine the medical necessity for these services.

Self-funded groups have the option to opt in therefore, your outcomes may vary by plan.

To access the updated guidelines, go to the Radiation Oncology section of eviCore’s website and type Independence Blue Cross in the Search field.

Summary of changes

The following outlines changes to the Radiation Therapy Clinical Guidelines as of October 1, 2020:

There are three new guidelines and 13 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:

  1. Radiation Therapy for Skin Cancer – Basal cell and Squamous cell Cancers
  2. Radiation Therapy for Skin Cancer – Melanoma

  3. In previous versions, the two new guidelines were combined into one guideline titled “Radiation Therapy for Skin Cancer.”

  4. Xofigo® (Radium-223)

In previous versions, this new guideline was combined into the guideline titled “Radiation Therapy for Bone Metastases.”

Criteria changes:

  1. Image-Guided Radiation Therapy (IGRT) for specific diagnoses
  2. Proton Beam Therapy for uveal melanoma
  3. Radiation Therapy for Bone Metastases
  4. Radiation Therapy for Brain Metastases
  5. Radiation Therapy for Breast Cancer
  6. Radiation Therapy for Cervical Cancer
  7. Radiation Therapy for Non-Small Cell Lung Cancer
  8. Radiation Therapy for Pancreatic Cancer
  9. Radiation Therapy for Prostate Cancer

  10. Consistent with the updated National Comprehensive Cancer Network (NCCN) Guidelines (March 2020), eviCore has updated their Guidelines for Prostate Cancer to only consider hypofractionation medically necessary for the following populations: low risk, intermediate risk, or high risk when not treating pelvic lymph nodes. The Guidelines will no longer consider conventional fractionation medically necessary for these populations.

  11. Radiation Therapy for Skin Cancer – Basal cell and Squamous cell Cancers

  12. This is a new guideline that was part of the Radiation Therapy for Skin Cancer guideline.

  13. Radiation Therapy for Skin Cancer – Melanoma

  14. This is a new guideline that was part of the Radiation Therapy for Skin Cancer guideline.

  15. Radiation Therapy for Small Cell Lung Cancer
  16. Radiation Treatment with Xofigo® (Radium-223)

This is a new guideline that was part of the Radiation Therapy for Bone Metastases guideline.

Policies and guidelines          

The following policies include a link to the Radiation Therapy Clinical Guidelines that eviCore uses and a list of procedure codes effective October 1, 2020:

  • Commercial: #09.00.56k: Radiation Therapy Services
  • Medicare Advantage: #MA09.020k: Radiation Therapy Services

To view these policies, visit our Medical Policy Portal.