eviCore Radiation Therapy Clinical Guidelines

eviCore covers specific, limited radiation modalities—e.g., coronary intravascular brachytherapy for in‑stent restenosis (BMS/SVG) and recurrent DES; hyperthermia only when given with radiation for superficial recurrent melanoma, chest‑wall breast recurrence or recurrent cervical nodes (≤4 cm); IGRT when IMRT is approved or in enumerated 3DCRT scenarios; neutron therapy for unresectable/recurrent salivary gland cancers; PBT only for select indications (skull‑base chordoma/chondrosarcoma, select uveal melanoma, select unresectable HCC, Stage IIA seminoma), plus defined 3DCRT/IMRT/SRS/WBRT/palliative/breast/Radium‑223 uses—while many other uses (deep/whole‑body hyperthermia, most PBT indications including prostate, SBRT for initial bone mets, electronic brachytherapy, and other non‑listed brachytherapy indications) are investigational or not medically necessary. Key requirements include strict treatment limits and documentation (e.g., hyperthermia ≤10 treatments, no concurrent/planned chemo or hormonal therapy and depth ≤4 cm; IGRT requires IMRT approval and has bundling/coding rules), and rigorous evidence/documentation for PBT—especially HCC, which mandates a multidisciplinary tumor‑board note or six specific items proving contraindication to ablative/transarterial/photon/SBRT approaches, tumor ≤16 cm, preservation of ≥700 cc normal liver, and ability to deliver the specified proton regimen.