EviCore Radiation Oncology Clinical Guidelines

EviCore’s guidelines list specific medically necessary radiation therapies (eg, IGRT when IMRT is approved for many tumor sites, limited coronary brachytherapy for in‑stent restenosis, hyperthermia for select superficial recurrences, and PBT for defined indications such as skull‑base chordoma/chondrosarcoma, uveal melanoma, select sinonasal/skull‑base/head‑and‑neck tumors, certain large HCC lesions, Stage IIA seminoma and some craniospinal/pediatric cases) while deeming many other uses experimental, investigational, or not medically necessary (eg, PBT for prostate, locally advanced lung, primary CNS, many GI/sarcoma sites; neutron beam therapy; deep/regional/whole‑body hyperthermia; IGRT for superficial/electron therapy) and specifying billing/coding and out‑of‑scope exclusions. Prior authorization requires recent (≤60 days) radiation oncology consultation, a radiation prescription/treatment plan, staging imaging and treating‑provider reports, and for PBT usually documentation of dosimetric advantage or enrollment in prospective trials/registries (with CMS/NCD/LCD policies superseding for Medicare).