This version of the policy will become effective 01/21/2020.
eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 01/21/2020. These guidelines are available online at: https://www.evicore.com/resources/Pages/providers.aspx.
The following HCPCS codes were added to Attachment A of this policy: A4648, A4650, A9517, A9527, A9530, A9563, A9564, A9600, A9604, C1715, C1716, C1717, C1719, C2634, C2635, C2636, C2637, C2638, C2639, C2640, C2641, C2642, C2643, C2644, C2698, C2699, C9725, C9728
Note: On 12/04/2019, Attachment A of this policy was updated to incorporate coding changes effective 01/01/2020.
The following HCPCS code was added to Attachment A of this policy: A9590
The following HCPCS code was removed from Attachment A of this policy: C9408
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.