Effective July 1, 2019, CareCore National, LLC d/b/a eviCore healthcare (eviCore) will be using updated
Radiation Therapy Clinical Guidelines for AmeriHealth members.
AmeriHealth has delegated the responsibility for utilization management activities for certain radiation therapy services to eviCore for all AmeriHealth 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
AmeriHealth New Jersey or
AmeriHealth in the Search field to access AmeriHealth New Jersey or AmeriHealth Pennsylvania guidelines, and then choose
Current or
Future as applicable to view the appropriate version of the
Radiation Therapy Clinical Guidelines.
Summary of changes
The following outlines changes to the
Radiation Therapy Clinical Guidelines effective 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)
Policy and guidelines
Medical Policy #09.00.56i: Radiation Therapy Services, which includes a link to the Radiation Therapy Clinical Guidelines that eviCore uses and a list of procedure codes, was posted as a Notification on April 1, 2019, and will go into effect July 1, 2019.
To view the Notification for this policy, visit our
Medical Policy Portal and select
Accept and Go to Medical Policy Online. Then select
Active Notifications.