As previously communicated in a Partners in Health UpdateSM article, as of July 1, 2019, CareCore National, LLC d/b/a eviCore healthcare (eviCore) is 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 uses the Radiation Therapy Clinical Guidelines to determine the medical necessity for these services.
To access the current 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 to view the Radiation Therapy Clinical Guidelines.
Summary of 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)
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 is effective as of July 1, 2019.
To view this policy, visit our Medical Policy Portal.