As of October 1, 2018, CareCore National, LLC d/b/a eviCore healthcare (eviCore) is using updated Radiation Therapy Clinical Guidelines for AmeriHealth members.
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 is now using the updated Radiation Therapy Clinical Guidelines to determine the medical necessity for these services. The updated guidelines can be found here or in the Resources section of eviCore’s website.
Summary of changes
The following outlines the changes to the Radiation Therapy Clinical Guidelines as of 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 healthcare 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 these changes do not affect the criteria sections. Note: A detailed overview of changes can be found in the Revision History section at the end of the updated guidelines.
Policy and guidelines
Medical Policy #09.00.56f: Radiation Therapy Services is in effect as of 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 this policy, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online and then type the policy name or number in the Search field.