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Radiation Therapy Services (Independence)
MA09.020x

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

The Company has delegated 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 2D, 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., Iodine-131, 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.

EVICORE RADIATION ONCOLOGY PROGRAM CLINICAL GUIDELINES

eviCore utilizes any official, applicable, and published policy related communications by Centers for Medicare & Medicaid Services (CMS), Medicare Administrative Contractors (MAC), and its Radiation Oncology Program Clinical Guidelines for medical necessity determination. Please see the administrative guidelines entitled CMS Policy Hierarchies and Application found under supplemental information on eviCore's website for further information. 

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

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, radiation therapy services are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria for the services are met. However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Description

The Company has delegated the responsibility for utilization management activities of radiation therapy services to EviCore by Evernorth Health Services​ to manage requests for outpatient, nonemergent radiation therapy services.

eviCore will utilize any official, applicable, and published policy related communciations by Centers for Medicare & Medicaid Services (CMS), Medicare Administrative Contractors (MAC), and​ its Radiation Therapy Clinical Guidelines to determine the medical necessity for select radiation therapy services, and to direct the application of these services to our members.

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, the 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 Blue Cross Mediare Advantage. Available at: https://www.evicore.com/provider/clinical-guidelines-details?solution=radiation oncology&hPlan=Independence Blue Cross​​. Accessed ​July 13, 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.


Coding and Billing Requirements

Policy History

Revisions From MA09.020x:
11/05/2026This version of the policy will become effective 11/05/2026.​

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

Revisions From MA09.020w:
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. ​

Revisions From MA09.020v: 
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 enhanced 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 MA09.020u: 
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 MA09.020t:
01/01/2025This policy has been identified for the HCPCS code update, effective 01/01/2025.

The following HCPCS codes have been added to Attachment A of this policy as medically necessary:
G0562 Therapeutic radiology simulation-aided field setting; complex, including acquisition of PET and CT imaging data required for radiopharmaceutical-directed radiation therapy treatment planning (i.e., modeling) (formerly C9794)

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 codes were termed and have been removed from Attachment A of this policy:
C9794, C9795 ​​

Revisions From MA09.020s:
10/01/2024This version of the policy will be published 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: 

77789, 77790, 77799, C9726, G0458, 0745T, 0746T, 0747T, G0339, G0340, 77423, S8030, 77600, 77605, 77610, 77615, 77620, 77499, A9609, C9794, C9795, A9607, A9699, 76965, 61796, 61797, 61798, 61799, ​​61800​
​
Revisions From MA09.020r:
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 MA09.020q:​
​01/01/2024

​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​
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 MA09.020p:
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​ MA09.020o:
10/15/2​022eviCore healthcare has revi​​sed 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 MA09.020n:
05/01/2022This version of the policy will be published on 06/20/2022 with a retro-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 to Attachment A of this policy: 61796, 61797, 61798, 61799, 61800, 77423, 77600, 77605, 77610,  77615, 77620, 77499, 77299, 77789, 77790

The following HCPCS codes were removed to Attachment A of 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 MA09.020m:
10/01/2021This version of the policy will become effective 10/1/2021.

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

Revisions From MA09.020l:
08/01/2021eviCore healthcare has r​evised their Radiation Therapy Clinical Guidelines. These guidelines will become effective 08/01/2021.  Refer to the guidelines available on ​eviCore's website. ​
​
Revisions From MA09.020k:
10/01/2020eviCore 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. ​This 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 MA09.020j:
01/21/2020eviCore heal​thcare 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 MA09.020i:
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 MA09.020h:
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 MA09.020g:
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 MA09.020f:
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.

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 MA09.020e:
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

Revisions From MA09.020d:
09/01/2017Independence Blue Cross (Independence) delegates precertification of non-emergent outpatient radiation therapy services for all Medicare Advantage HMO, POS, and PPO members to CareCore National, LLC d/b/a eviCore healthcare (eviCore), an independent company. eviCore maintains Radiation Therapy Clinical Guidelines for Independence that contain medical necessity criteria used during the precertification process for our members.

Effective September 1, 2017, Independence will update its Radiation Treatment of Breast Carcinoma guideline to indicate that a hypofractionated regimen is the preferred treatment for patients with early stage (T1-2N0) breast carcinoma who meet certain criteria. For these patients, a request for precertification of conventional fractionation will require a peer-to-peer call with an eviCore Radiation Oncologist.

The Independence Blue Cross Radiation Therapy Clinical Guidelines – FUTURE - Effective 9/1/2017 are available for review on eviCore’s website. These guidelines include the updated criteria for treatment of breast carcinoma using hypofractionated radiation therapy.

Revisions From MA09.020c:
01/01/2017This version of the policy will become effective 01/01/2017.

Revisions From MA09.020b:
09/02/2016The policy has been reviewed and reissued to communicate the Company’s continuing delegation of precertification/preapproval of radiation therapy services to CareCore National, LLC d/b/a eviCore healthcare (eviCore) for outpatient, non-emergent radiation therapy services.

eviCore healthcare has revised their Radiation Therapy Guidelines. These guidelines will become effective September 2, 2016. Refer to the guidelines available on ​eviCore's website. ​

Furthermore, effective September 2, 2016, eviCore healthcare's guidelines will be utilized for the management of Radium Ra 223 dichloride (Xofigo®) Injections.
01/1/2016This policy was reviewed and updated to communicate Company's continued position on Radiation Therapy Services. On 12/30/2016 Attachment A was updated with coding changes.

Revisions From MA09.020a:
08/19/2015This policy was reviewed and reissued in accordance with the Company's Policy Confirmation Review track. CareCore National LLC/ CareCore was changed to CareCore National, LLC d/b/a eviCore healthcare (eviCore) throughout the document. Link to the guidelines was updated.
05/01/2015Policy #MA09.020a updated to communicate the Company is delegating precertification/preapproval of additional radiation therapy services to CareCore National, LLC (CareCore) for outpatient, non-emergent radiation therapy services. Policy #MA09.020a also supersedes MA08.069, MA08.014, MA09.007

Revisions From MA09.020:
01/01/2015New medical policy MA09.020 issued to communicate the Company is delegating precertification/preapproval of radiation therapy services to CareCore National, LLC (CareCore) for outpatient, non-emergent radiation therapy services.
11/5/2026
11/5/2026
MA09.020
Medical Policy Bulletin
Medicare Advantage
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.