eviCore Radiation Therapy Clinical Guidelines

eviCore deems specific radiation modalities medically necessary for defined indications—e.g., coronary intravascular brachytherapy only as adjunct for in‑stent restenosis (BMS and select DES), hyperthermia only for superficially recurrent melanoma/chest‑wall breast recurrence/recurrent cervical lymph nodes, IGRT when IMRT is approved or for listed 3DCRT scenarios, neutron therapy for select salivary‑gland cancers, and PBT only for limited tumors (skull‑base chordoma/chondrosarcoma, uveal melanoma, select unresectable HCC, Stage IIA seminoma)—while broader uses of hyperthermia, neutron beam, and PBT (including newly diagnosed prostate cancer) are experimental, investigational, or not medically necessary. Key requirements include hyperthermia limits (≤10 treatments, ≤4 cm depth, no concurrent/planned systemic therapy for metastatic disease), IGRT indication/billing constraints, and specific, often extensive documentation for exceptions—notably multidisciplinary tumor‑board/IR consult and proof that 3DCRT/IMRT or SBRT cannot meet liver dose constraints (e.g., inability to maintain mean normal liver dose <28 Gy or to deliver SBRT 30 Gy/5 fx or spare 700 cc) plus tumor size, dose and fractionation criteria for PBT in HCC.