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Radiation Therapy Services (Independence)
09.00.56w

Policy

This policy does not apply to members for whom eviCore's Radiation Therapy Services is not applicable. This policy only applies to members for whom the Radiation Therapy Program is applicable. Individual benefits must be verified.
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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.​

 This policy does not apply to radiation therapy treatment requests performed in an inpatient setting or emergent situations.

The Company has delegated the responsibility for utilization management activities for the following radiation therapy services to EviCore by Evernorth Health Services​ for outpatient, nonemergent radiation therapy services. eviCore utilizes Radiation Therapy Clinical Guidelines​ to determine the medical necessity for the following services:
  • External beam including two dimensional (2D), three dimensional (3D) conformal, ​biology-guided radiation therapy (BgRT), intensity-modulated radiation therapy (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 intraoperative techniques (IORT)
  • Hyperthermia
  • Neutron radiotherapy
  • Radiolabeled drugs used for radiation therapy (e.g., Radium-223 dichloride [Xofigo®], 177Lu-dotatate [Lutathera®], lutetium Lu 177 vipivotide tetraxetan [Pluvicto®])
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 EviCore by Evernorth Health Services 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

EviCore by Evernorth Health Services​ 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

EviCore by Evernorth Health Services​. Radiation ​Oncology Clinical Guidelines: Independence Administrators. Available at: https://www.evicore.com/provider/clinical-guidelines-details?solution=radiation oncology​. Accessed ​January 21, 2026

EviCore by Evernorth Health Services​. Radiation ​Oncology Clinical Guidelines: Independence Blue Cross. Available at: https://www.evicore.com/provider/clinical-guidelines-details?solution=radiation oncology​. Accessed January 21, 2026.

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.


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Coding and Billing Requirements

Policy History

Revisions From 09.00.56w:
02/25/2026This version of the policy will become effective 02/25/2026. EviCore has revised their Radiation Oncology Clinical Guidelines. Refer to the guidelines available on ​eviCore's website. ​

The following codes have been added ​to Attachment A of this policy: 
19294, 19296, 19297, 19298, 31643, 32553, 41019, 49411, 49412, 55875, 55876, 55920, 57155, 57156, 58346, 61796, 61797, 61798, 61799, 61800, 76873, 76965, 77261, 77262, 77263, 77280, 77285, 77290, 77293, 77295, 77300, 77301, 77306, 77307, 77316, 77317, 77318, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77399, 77402, 77412, 77417, 77427, 77431, 77432, 77435, 77436, 77439, 77469, 77470, 77499, 77790, 77799, 0745T, 0746T​

Revisions From 09.00.56v:
01/01/2026This version of the policy will become effective 01/01/2026.​

eviCore healthcare has revised their Radiation Oncology Clinical Guidelines. Refer to the guidelines available on ​eviCore's website. ​​

Zevalin and Azedra radiopharmaceuticals have been removed because they are no longer within scope of the eviCore enhance utilization management program.​​

​The following CPT codes have been added to Attachment A of this policy: 
77436, 77437, 77438, 77439​
 
The following CPT/HCPCS codes have been removed from Attachment A of this policy:
A9543, A9590, 77750, 79403, 77014,​ 77385, 77386, 77401, 0394T, G6001, G6002, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, G6017 ​

The following CPT codes have been revised in this policy: 
77402, 77407, 77412​

Revisions From 09.00.56u
07/16/2025This version of the policy will become effective 07/16/2025.

eviCore healthcare has revised their Radiation Oncology Clinical Guidelines. Refer to the guidelines available on ​eviCore's website. ​

This policy version contains two updates to eviCore's clinical guidelines: Pluvicto effective 7/15 (notification May 2025) and a quarterly update to multiple services effective 7/16 (notification June 2025). Both clinical guideline versions will be combined and effective 7/16 to ensure continuity of care. 

Revisions From 09.00.56t:
01/01/2025This policy has been identified for the HCPCS code update, effective 01/01/2025.

The following HCPCS code has been added to Attachment A of this policy as medically necessary:
G0563 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions (formerly C9795)​

The following HCPCS code was termed and has been removed from Attachment A of this policy:
C9795 

Revisions From 09.00.56s:​
10/01/2024This version of the policy will be issued on 12/16/2024 with a retroactively effective date of 10/01/2024.

eviCore healthcare has revised their Radiation Oncology Clinical Guidelines. Refer to the guidelines available on ​eviCore's website. ​

​Biology-guided radiation therapy has been added as medically necessary.

​The following CPT codes have been added to Attachment A of this policy as medically necessary:
​
0747T, 77423, 77600, 77605, 77610, 77615, 77620, 77789, A9607, A9609, A9699, C9795, G0339, G0340, G0458

​The following CPT codes have been removed from Attachment A of this policy: 

77316, 77317, 77318, 77432, 77435, 77301, 77338, 19294, 77469, 77427, 77431, 77470, 77261, 77262, 77263, 77280, 77285, 77290, 77293, 77417, 77295, 77300, 77306, 77307, 77321, 77331, 77332, 77333, 77334, 77336, 77370, 77399, 19296, 19297, 19298,  31643, 32553, 41019, 49411, 49412, 55875, 55876, 55920, 57155, 57156, 58346, 76873​

Revisions From 09.00.56r:​
04/08/2024This version of the policy will become effective 04/08/2024.

eviCore healthcare has revised their Radiation Oncology Clinical Guidelines. Refer to the guidelines available on ​eviCore's website. ​

Revisions From 09.00.56q:​
10/01/2023This version of the policy will become effective 10/01/2023.

eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. Refer to the guidelines available on ​eviCore's website. ​

The following CPT codes were removed from Attachment A of this policy: 0745T, 0746T, 0747T. 

The following HCPCS codes were removed from Attachment A of this policy:
A9607 Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie​.​

Revisions from 09.00.56p:
01/01/2023This policy has been identified for the CPT code update, effective 01/0123.

The following CPT codes have been added to Attachment A of this policy: 0745T, 0746T, 0747T. ​

Revisions from 09.00.56o:
10/15/202​2​eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 10/15/2022. Refer to the guidelines available on ​eviCore's website. ​

Effective 10/01/2022, the policy was identified for a code update. The following coding changes were made to the policy. ​

The following HCPCS code was added to Attachment A of this policy: ​A9607​​

The following HCPCS codes were removed to Attachment A of this policy: A9699

Revisions From 09.00.56n:​
05/01/2022This version of the policy will be published on 06/20/2022 with an effective date of 05/01/2022. 

eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. Refer to the guidelines available on ​eviCore's website. ​

The following HCPCS codes was added to Attachment A of this policy:

​A9699 ​Radiopharmaceutical, therapeutic, not otherwise classified​

The following CPT codes were removed from Attachment A to this policy: 61796, 61797, 61798, 61799, 61800, 77423, 77600, 77605, 77610,  77615, 77620, 77499, 77299, 77789, 77790

The following HCPCS codes were removed from Attachment A to this policy:​ A9527, A9530, 76965, A4648, A4650, A9517, C1715, C1716, C1717, C1719, C2616, C2634, C2635, C2636, C2637, C2638, C2639, C2640, C2641, C2642, C2643, C2644, C2698, C2699, C9725, C9726, C9728, G0458, G0339, G0340.

Revisions From 09.00.56m:​
10/01/2021This version of the policy will become effective 10/1/2021.

eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. Refer to the guidelines available on ​eviCore's website. ​​

Revisions From 09.00.56l:
08/01/2021This version of the policy will become effective 08/1/2021.

eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. Refer to the guidelines available on ​eviCore's website. ​

Revisions From 09.00.56k:
10/01/2020This version of the policy will become effective 10/1/2020.

It was updated to reflect that eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 10/01/2020. Refer to the guidelines available on ​eviCore's website. ​

Revisions From 09.00.56j:
01/21/2020eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 01/21/2020. Refer to the guidelines available on ​eviCore's website. ​

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 with HCPCS coding changes effective 01/01/2020.

Added: A9590
Removed: C9408

Revisions From 09.00.56i:
07/01/2019eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 07/01/2019. Refer to the guidelines available on ​eviCore's website. ​

Revisions From 09.00.56h:
03/01/2019eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 03/01/2019. Refer to the guidelines available on ​eviCore's website. ​

Iobenguane I-131 [Azedra®] was added to the list of radio-labeled drugs used for radiation therapy that eviCore manages.

Coding:

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.

Added: C9408
Removed: 0190T, 0333

As a result of these coding updates, the version of this policy was revised from “g” to “h.”

Revisions From 09.00.56g:
01/01/2019This version of the policy will become effective 01/01/2019.

This policy has been identified for the CPT/HCPCS code update, effective 01/01/2019.

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, C9408, C9726

The following CPT code was termed and removed from Attachment A of this policy: 0190T

The following HCPCS code was termed and removed from Attachment A of this policy: C9031

The following Revenue code was removed from Attachment A of this policy: 0333

The following CPT narrative has been revised in Attachment A of this policy: 77387

Revisions From 09.00.56f:
10/01/2018This version of the policy will become effective 10/01/2018.

eviCore healthcare has revised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 10/01/2018. Refer to the guidelines available on ​eviCore's website. ​

All references to Precertification/Preapproval have been removed from this policy.

Language was added stating that this policy does not apply to self-funded groups for whom eviCore's Radiation Therapy Services program is not applicable.

The following HCPCS code was removed from Attachment A of this policy: S8030

The following codes used to report Lutathera (Lutetium; Lu 177 dotatate) were added to Attachment A of this policy: 79101, C9031.

Guidelines and utilization management for Lutathera (Lutetium; Lu 177 dotatate) through eviCore healthcare will become effective 07/01/2018.

Revisions From 09.00.56e:
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT code has been added to Attachment A of this policy: 19294
The following CPT code has been removed from Attachment A of this policy: 77422

Effective 10/05/2017 this policy has been updated to the new policy template format.
2/25/2026
3/23/2026
09.00.56
Medical Policy Bulletin
Commercial
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