eviCore Radiation Therapy Clinical Guidelines

eviCore deems medically necessary a limited set of radiation therapies — e.g., coronary intravascular brachytherapy for specified in‑stent restenosis, hyperthermia with radiation for selected superficial/recurrent tumors (≤4 cm depth, ≤10 treatments, not with concurrent chemo for metastatic disease), IGRT when IMRT is approved or in specified 3DCRT settings, neutron therapy for select salivary gland cancers, and proton beam therapy for skull‑base chordoma/chondrosarcoma, uveal melanoma (when preferred to brachytherapy), Stage IIA seminoma, and select unresectable HCC — while labeling expanded brachytherapy indications, most PBT uses (eg, prostate, ablative/SBRT), deep/regional hyperthermia, and most neutron/PBT applications as experimental/investigational or not medically necessary. Key requirements include strict documentation (multidisciplinary tumor board minutes or specified consult notes), dosimetric proof that photon/IMRT or SBRT cannot meet organ‑at‑risk constraints (eg, mean normal liver dose ≤28 Gy for photon plans and RTOG‑1112 SBRT constraints), limits on HCC size/liver reserve, and specified dose/fractionation parameters (eg, PBT ≥50 GyE in 22 fractions for HCC).