Commercial

Radiation Therapy Services (Independence)
09.00.56k

Policy



 

This policy does not apply to self-funded groups for whom eviCore's Radiation Therapy Services program is not applicable; individual benefits must be verified.

The Company has delegated the responsibility for utilization management activities for the following radiation therapy services to CareCore National, LLC d/b/a eviCore healthcare (eviCore), for outpatient, non-emergent radiation therapy services. eviCore utilizes Radiation Therapy Clinical Guidelines, available at https://www.evicore.com/resources/Pages/providers.aspx to determine the medical necessity for the following services:
  • External beam including 2D, 3D conformal, intensity-modulated (IMRT), tomotherapy, image-guided radiation therapy (IGRT), stereotactic body radiation therapy (SBRT), and stereotactic radiosurgery (SRS);
  • Proton beam radiation therapy;
  • Brachytherapy including low-dose rate (LDR), high-dose rate (HDR), and outpatient intra-operative techniques (IORT);
  • Hyperthermia;
  • Neutron radiotherapy;
  • Radio-labeled drugs used for radiation therapy (e.g., Radium Ra 223 dichloride [Xofigo®], ibritumomab tiuxetan [Zevalin®], Lutetium; Lu 177 dotatate [Lutathera], iobenguane I-131 [Azedra®])

The use of radiation therapy services, which are listed in this policy, for conditions not addressed in the eviCore Radiation Therapy Clinical Guidelines, may be considered Experimental/Investigational or not medically necessary, and, therefore, not covered.

REQUIRED DOCUMENTATION

The individual’s medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, radiation therapy services are covered under the medical benefits of the Company’s products when the medical necessity criteria for the services are met. However, services that are identified as experimental/investigational or not medically necessary are not eligible for coverage or reimbursement by the company.

The CareCore National, LLC d/b/a eviCore healthcare (eviCore) Radiation Therapy Clinical Guideline algorithms will not be applied for those self-funded groups for whom eviCore's Radiation Therapy Services program is not applicable. Individual benefits must be verified.

Description

CareCore National, LLC d/b/a eviCore healthcare (eviCore) Radiation Therapy Clinical Guidelines are based on evidence-based guidelines and recommendations from national and international medical societies, and evidence-based medicine research centers, including, but not limited to, American Society of Radiation Oncology [ASTRO], National Comprehensive Cancer Network [NCCN], and American College of Radiology [ACR].

References


CareCore National, LLC d/b/a eviCore healthcare. Radiation Therapy Clinical Guidelines. Available at: https://www.evicore.com/resources/Pages/providers.aspx. Accessed June 16, 2020.

Coding

CPT Procedure Code Number(s)
See Attachment A

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)
See Attachment A

Revenue Code Number(s)
See Attachment A


Coding and Billing Requirements


Policy History

10/1/2020
10/1/2020
Medical Policy Bulletin
Commercial
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No