Updated Radiation Therapy Clinical Guidelines

July 2, 2020

Effective October 1, 2020, eviCore healthcare (eviCore), an independent specialty benefit management company, will use 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 commercial Independence members. eviCore will use the updated Radiation Therapy Clinical Guidelines to determine the medical necessity for these services.

To access the current and future guidelines,  go to the Radiation Oncology section of eviCore's website, type Independence Blue Cross in the Search field, and then choose Current or Future, as applicable, to view the appropriate version of the Radiation Therapy Clinical Guidelines.

Summary of changes

The following changes to the Radiation Therapy Clinical Guidelines are effective 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

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

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

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

11.  Radiation Therapy for Skin Cancer – Melanoma

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

12.  Radiation Therapy for Small Cell Lung Cancer

13.  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, which include a link to the Radiation Therapy Clinical Guidelines that eviCore uses and a list of procedure codes will be effective October 1, 2020:

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

To view the Notifications for these policies, visit our Medical Policy Portal on or after July 15, 2020.