EviCore Radiation Oncology Clinical Guidelines

EviCore’s Radiation Oncology guideline (effective Oct 1, 2024) deems biology‑guided RT (BgRT) and neutron beam therapy not medically necessary for all indications, limits coronary artery brachytherapy to a single treatment for specified in‑stent restenosis, approves hyperthermia only with EBRT for superficially recurrent melanoma, chest‑wall breast recurrence, or recurrent cervical lymph nodes (≤4 cm depth, ≤10 treatments delivered twice weekly, not with concurrent systemic therapy), considers IGRT medically necessary when IMRT is used or for a specified list of 3DCRT sites, and designates proton beam therapy (PBT) medically necessary for a defined Group‑1 list (e.g., pediatric/craniospinal tumors, skull‑base/ocular tumors, re‑irradiation where photon doses would exceed tolerances, select sarcomas and hepatobiliary tumors) but not medically necessary for a broad Group‑2 list (eg, prostate, many common adult pelvic/abdominal cancers, palliative/metastatic disease). Prior authorization requires recent radiation oncology consultation, imaging, treatment prescription/plan and dosimetry, and for PBT in ASTRO Group‑2 or other nonstandard uses documentation of enrollment in a prospective clinical trial or registry (or detailed dosimetric justification for re‑irradiation exceptions).