This version of the policy will become effective 03/01/2019.
eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 03/01/2019. These guidelines are available online at: https://www.carecorenational.com/benefits-management/radiation-therapy/radiation-therapy-tools-and-criteria.aspx.
Iobenguane I-131 [Azedra®] was added to the list of radio-labeled drugs used for radiation therapy that eviCore manages.
The following CPT codes were added to Attachment A of this policy: 61796, 61797, 61798, 61799, 61800, 79005, 79403
The following HCPCS codes were added to Attachment A of this policy: A9513, A9543, C2616, C9726
The following HCPCS code was removed from Attachment A of this policy: C9031
The following CPT narrative has been revised in this policy: 77387
Note: On 12/18/2018, Attachment A of this policy was updated with coding changes effective 01/01/2019.
Removed: 0190T, 0333
As a result of these coding updates, the version of this policy was revised from “g” to “h.”
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.