EviCore Radiation Oncology Clinical Guidelines

EviCore’s Radiation Oncology guideline (effective 01/01/2026) rules BgRT and neutron beam therapy not medically necessary, deems proton beam therapy medically necessary only for specified Group 1 curative indications (e.g., pediatric tumors, select CNS/ocular/base‑of‑skull/spine/retroperitoneal/primary bone tumors, select hepatobiliary, thymic/mediastinal disease, and reirradiation where photon plans would exceed organ‑at‑risk constraints) while listing many common sites (prostate, lung, breast, pancreas, rectum/anal, bladder, gynecologic, lymphoma, metastatic/palliative use, etc.) as Group 2 not medically necessary except in trials; it also allows a single coronary artery brachytherapy treatment for in‑stent restenosis and limited hyperthermia use for select superficial recurrences (no tumor >4 cm depth and no concurrent systemic therapy). Key requirements include prior authorization with detailed documentation (consultation, staging, prior RT records), comparative proton vs photon dosimetry demonstrating meaningful OAR sparing when claiming PBT benefit, motion‑management documentation for thoracic/upper‑abdominal targets, enrollment in a prospective clinical trial/registry for Group 2 PBT uses, hyperthermia limited to ≤10 treatments twice weekly, and IGRT coverage only when IMRT is approved with specified billing restrictions.