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Updated Radiation Therapy Clinical Guidelines

August 8, 2018

Effective October 1, 2018, updated Independence Radiation Therapy Clinical Guidelines will be used by CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company.

Independence delegates precertification of non-emergent outpatient radiation therapy services for all commercial HMO, POS, EPO, and PPO members and Medicare Advantage HMO, POS, and PPO members to eviCore. eviCore will use the updated Radiation Therapy Clinical Guidelines to determine the medical necessity for these services. For the current guidelines, go to the Resources section of eviCore?s website.

Summary of changes

The following outlines the changes to the Radiation Therapy Clinical Guidelines effective 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 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 they do not affect the criteria sections.

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, were posted as Notifications on June 29, 2018, and will go into effect October 1, 2018:

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

To view the Notifications for these policies, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Commercial or Medicare Advantage under Active Notifications.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
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