eviCore Radiation Oncology Clinical Guidelines

eviCore’s Radiation Oncology guideline designates specific medically necessary therapies — limited coronary intravascular brachytherapy for two in‑stent restenosis scenarios, hyperthermia only with external beam RT for superficially recurrent melanoma/chest‑wall breast recurrence/recurrent cervical nodes (no concurrent systemic therapy and tumor depth ≤4 cm), IGRT only when IMRT is approved or in specified 3DCRT indications, and proton beam therapy only for a defined Group‑1 list (e.g., skull base chordoma/chondrosarcoma, uveal melanoma, select unresectable HCC, Stage IIA seminoma, CSI indications, pediatric malignancies) while neutron beam and many other PBT uses are considered EIU or not medically necessary. Key requirements include prior authorization with a Radiation Oncology consultation within 60 days documenting H&P, stage, radiation prescription and plan, imaging and provider reports, tumor‑board or detailed clinical justification for off‑guideline PBT (stringent HCC documentation), and treatment limits such as hyperthermia ≤10 sessions (twice weekly).