Medical Oncology Value-Based Pathways

This EviCore value‑based pathways document (effective 3/1/2025) lists preferred, evidence‑based oncology regimens by cancer type and clinical scenario and directs coverage toward specific regimens tied to stage, histology, molecular biomarkers and prior‑therapy status, though the provided excerpt is a references section and does not itself state explicit coverage criteria. Key requirements include plan‑level use of preferred oncology products, biomarker thresholds (e.g., PD‑L1 CPS, HER2, dMMR/MSI‑H, EGFR/BRAF/RAS, BRCA/PALB2, del(17p)/TP53), prior‑therapy restrictions (e.g., “only if no prior CPI,” prior platinum non‑progression for maintenance), and documentation of diagnosis/stage, molecular testing results, prior treatment history/response, and transplant intent/eligibility as applicable.

"Anal cancer — Localized Disease: Definitive Chemoradiation: Mitomycin + 5FU (fluorouracil); Mitomycin + capecitabine."