eviCore Radiation Therapy Clinical Guidelines

eviCore’s guideline authorizes a limited set of radiation modalities — e.g., coronary intravascular brachytherapy for in‑stent restenosis, hyperthermia plus radiation for select superficial/recurrent tumors, IGRT when IMRT (or specific 3DCRT scenarios) is approved, neutron therapy for select salivary‑gland cancers, and Proton Beam Therapy only for skull‑base chordoma/chondrosarcoma, select uveal melanoma, Stage IIA seminoma and highly selected unresectable HCC — while deeming most other indications (including routine PBT for prostate, many head/neck and esophageal uses, and other listed indications) investigational/not covered. Key requirements: IGRT is covered only with approved IMRT (or specified 3DCRT circumstances); hyperthermia is limited to ≤10 twice‑weekly treatments for lesions ≤4 cm depth with no concurrent/planned systemic therapy for metastatic disease; and PBT for HCC requires tumor‑board documentation or six specific supporting items proving contraindication/inability to meet liver dose constraints with other modalities, limited extra‑hepatic disease, tumor ≤16 cm and the ability to deliver the specified proton dose/fractionation while sparing ≥700 cc normal liver.