eviCore Radiation Therapy Clinical Guidelines

The eviCore guidelines approve a narrow set of radiation therapies (e.g., coronary intravascular brachytherapy for BMS/SVG ISR and recurrent DES ISR; superficial hyperthermia ≤4 cm depth with radiation for select superficial/recurrent tumors, ≤10 treatments; IGRT only when IMRT is approved or for specific 3DCRT situations; neutron therapy for select salivary gland cancers; Group‑1 proton beam therapy for defined indications such as skull‑base chordoma/chondrosarcoma, select HCC, uveal melanoma, Stage IIA seminoma, CSI and pediatric malignancies; specified 3DCRT/IMRT fractionation for anal and muscle‑invasive bladder cancer; bone metastasis and radium‑223 criteria) and excludes many other uses as experimental/investigational or not medically necessary (e.g., deep/whole‑body hyperthermia, most PBT Group‑2/3 indications, other brachytherapy uses, and separate IGRT billing with SRS/SBRT). Key requirements include robust documentation (multidisciplinary tumor‑board minutes or specified IR/dosimetry/constraint evidence for PBT in HCC), no concurrent systemic chemo/hormonal therapy with hyperthermia, use of FDA‑cleared BSD‑500 for superficial hyperthermia reimbursement, limits on treatment frequency/depth and IGRT technique per day, and inclusion of clinical notes, treatment plans, imaging and dosimetry to support medical necessity.