Evicore radiation therapy guidelines 2021. ) before submitting the case by web, phone, or fax.

Evicore radiation therapy guidelines 2021 2024 Abbreviation Definition GOG Gynecologic Oncology Group GS Gleason score Gy Gray HA-WBRT Hippocampal-avoidance whole brain radiation therapy HDR High-dose rate IGRT Image-guided radiation therapy ILROG International Lymphoma Radiation Oncology Group IMRT Intensity-modulated radiation therapy In addition, EviCore’s clinical guidelines include background and supporting information and citations for sources used to develop the guidelines. based on EviCore’s evidence-based clinical guidelines. A v1. 100. Updated February 2021 2 Prior Authorization Rules - Medicaid Medical / Surgical (Non-Behavioral Health) PRIOR AUTHORIZATION REQUIREMENTS THROUGH BCBSIL Reminder: Eligibility and benefits as well as prior authorization verification and submissions can be initiated online through the Availity Provider Portal®. Some clinical guidelines may have supplemental literature summaries available that provide commentary regarding clinical benefits and harms to the patient population being served. A As of 1 JAN 2023 v1. Please review all guidelines when submitting a prior authorization request. 0. 1, 2021 PRIOR AUTHORIZATION REQUIREMENTS* THROUGH EVICORE HEALTHCARE (EVICORE) • Outpatient Molecular Genetics • Outpatient Radiation Therapy • Musculoskeletal Services ­ Spine, Joint, Pain • Radiology Imaging Services • Outpatient Medical Oncology • Outpatient Sleep • Post-Acute Care • Outpatient Specialty Drug Radiation Therapy (Oncology) The terms of an individual's particular coverage plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD), or similar plan eviCore has released clinical guideline updates for the Radiation Oncology program. These guidelines are not meant to be all -inclusive, but are meant to be used in conjunction with the other coding resources and AMA Current Procedural Terminology (CPT) code book. 19M lives . Such techniques include: Conventional Isodose Planning, Complex 3D Conformal Intensity-Modulated Radiation Therapy (IMRT) Image-Guided Radiation Therapy (IGRT) Radiation Oncology Guidelines V1. I. A treatment plan in which a radiation therapy technique is intended to be used to treat the patient’s diagnosis requires authorization. Providers may begin contacting NIA on September 20, 2021 to seek prior authorization for procedures scheduled on or after October 1, 2021. Failure to provide all Radiation Therapy Prostate Cancer Request For NON-URGENT requests, please complete this document for authorization along with any relevant clinical documentation requested within this document (i. Rotational arc therapy . Contouring for three-dimensional conformal radiation therapy (3D-CRT) 2. 0 Effective October 1, 2021 Clinical guidelines for medical necessity review of radiation therapy viCore e Radiation Therapy Coding Guidelines These guidelines summarize definitions and appropriate use of several CPT® codes. com | 400 Buckwalter Place Blvd Bluffton, SC 29910 | 6 days ago · There may be instances in which your health plan policies take precedence over the EviCore by Evernorth clinical guidelines. 144. AD. 2024 Preface to the Radiation Oncology Guidelines RO. If a form of IMRT was selected, was 3D conformal technique considered? Yes No c. Enter your Health Plan name into the search field and click on the magnifying glass, open the clinical guidelines document. Radiation Oncology Clinical Guideline Updates eviCore has released clinical guideline updates for the Radiation Oncology program. Jun 15, 2023 · Radiation Oncology Appeals Requirements V1. EviCore’s clinical worksheets and guidelines are available online 24/7: If you require a copy of the guidelines that were used to make a determination on a specific request of treatment or services, please email the case number and request to: reqcriteria@EviCore. Intensity modulated radiation therapy (IMRT) Tomotherapy Rotational arc therapy Proton beam therapy Stereotactic body radiation therapy (SBRT) Number of fractions: _____ Number of fractions: _____ b. Precertification . 2022 Abbreviation Definition GOG Gynecologic Oncology Group GS Gleason score Gy Gray HA-WBRT Hippocampal-avoidance whole brain radiation therapy HDR High-dose rate IGRT Image-guided radiation therapy ILROG International Lymphoma Radiation Oncology Group IMRT Intensity-modulated radiation therapy Radiation Oncology Guidelines V1. 2024 Prior Authorization Requirements eviCore applies an evidence-based approach to evaluate the most appropriate EBRT External beam radiation therapy Abbreviations for Radiation Oncology Guidelines ©2024 EviCore by EVERNORTH 8 of 313 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www. We created proprietary evidence-based clinical guidelines Clinical Guidelines for Cardiac Implantable Devices (CID) V1. dates of service 1/1/2021 and beyond for the expanded membership network 9 Program Overview Prior authorization applies to services that are: • Outpatient • Elective / Non-emergent • Diagnostic Prior authorization does not apply to services that are performed in: • Emergency room care, please reference the eviCore Radiation Therapy Coding Guidelines located online: September 24, 2021 Raj Singla, MD Chief Operating Officer, Radiation Therapy Radiation Therapy eviCore Healthcare 400 Buckwalter Place Blvd, Blufton, SC 29910 rsingla@evcore. SLEEP . During the precertification process, eviCore reviews the complete treatment plan for coverage – rather than each procedure individually – for consistency with American College of Radiology/American Society for Radiation Oncology (ACR/ASTRO) correct coding guidelines. Radiation Oncology Guidelines V1. 918. Proton beam therapy The Radiation Therapy Review Program consists of prior authorization medical necessity determinations for specific radiation therapy procedures such as 2D and 3D Conformal, Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT), Brachytherapy, Hyperthermia, Proton Beam Therapy, Intensity-Modulated Radiation Therapy (IMRT eviCore Radiation Therapy Coding Guidelines. Guideline updates will become effective August 1, 2020: Please review all guidelines when submitting a prior authorization request. Coding edits are in line with CMS guidelines eviCore Radiation Therapy Program Platform Improvements Providers who have previously submitted Radiation Therapy prior authorization requests to eviCore on the legacy CareCore National (ISAAC) utilization management system will notice several differences in authorizations approved via and billing should align with the national billing guidelines for radiation therapy. Guideline updates will become effective November 1, 2022. ) before submitting the case by web, phone, or fax. Guideline updates will become effective September 1, 2021: Please review all guidelines when Radiation Oncology Guidelines V 1. The Health Plan Prior Authorization Services Prior authorization does NOT apply to services performed in: • Emergency Rooms Please note the following: All information provided by the NCCN is “Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Edit, sign, and share evicore radiation therapy physician worksheet online. Treatments for members who will be ongoing through January 1, 2021 do not need to be registered with eviCore unless the What is the radiation therapy treatment start date (mm/dd/yyyy)? eviCore is utilizing a clinical decision support submission model for this diagnosis. WBRT Whole brain radiation therapy EviCore by EVERNORTH 10 of 65 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) EviCore by Evernorth is pleased to provide prior authorization services for Clover Health for dates of service August 1, 2020 and beyond. Covered Service Prior authorization required? Oct 1, 2023 · recommendations for treatment and should never be used as treatment guidelines. eviCore will provide a medical necessity decision based on the treatment plan, plus any pertinent clinical documentation requested within this document (i. Prior authorization will be required for the following services: Advanced Imaging; Cardiac Imaging; eviCore healthcare (eviCore) will begin accepting prior authorization requests for physical therapy, occupational therapy, and chiropractic services on December 13,2021 for dates of service January 1, 2022 and after. 2023 ACE inhibitor — Angiotensin-converting enzyme inhibitor AMI — Acute myocardial infarction ARVC — Arrhythmogenic right ventricular cardiomyopathy AV — Atrioventricular CC — Complications/comorbid conditions CHF — Congestive heart failure CM — Cardiomyopathy The program’s purpose is to ensure that radiation therapy services provided to members are consistent with national guidelines. e. Reviewing a multi-phase plan when the physicist has done the work of summing the plans. Integrated Solutions . Page 1 of 2 eviCore healthcare | www. 4. CARDIOLOGY 46M lives RADIOLOGY . COM Relevant Medications If initiating the prior authorization by telephone, the caller should have the medical record(s) available. Jul 18, 2023 · Quick Reference Guide Aetna has contracted with eviCore healthcare, an independent specialty medical benefits management company, to provide prior authorization for expanded outpatient utilization management for its Medicare and commercial members. Adobe PDF Reader is required to view clinical worksheets documents. EviCore’s clinical worksheets and guidelines are available online 24/7: Radiation Therapy Skin Cancer Request eviCore. eviCore will provide a medical necessity decision based on the treatment plan, plus any pertinent clinical EviCore by Evernorth is limited to authorizing the procedure only. Providers must contact EviCore to accept the alternative recommendation beforethe start of treatment. recommendations for treatment and should never be used as treatment guidelines. These guidelines are not meant to be all-inclusive, but are meant to be used in conjunction with the other coding resources and AMA Current Procedural Terminology (CPT®) code book. 8924 FX: 843. Medical Oncology (including Lab), Radiation Therapy, Joint Surgery, Spine Surgery and Interventional Pain services require prior authorization from EviCore by Evernorth. Tune into our recent podcast episode with EviCore's post-CAM program specialists Dr. The EviCore . Prior authorization will be required for the following services: Advanced Imaging; Cardiac Imaging; Hypofractionation is a radiation therapy that increases the amount of radiation given each day while reducing the total length of treatment time by as much as fifty percent. com. 2022 1. New Guideline: • Pluvicto Guidelines with substantive changes: documentation requested within this document (i. 2024 ACE inhibitor — Angiotensin-converting enzyme inhibitor AMI — Acute myocardial infarction ARVC — Arrhythmogenic right ventricular cardiomyopathy AV — Atrioventricular CC — Complications/comorbid conditions CHF — Congestive heart failure NIA will begin the management of radiation therapy treatment modalities, image guidance (IGRT), port film, and Radiology Medical Specialty Solution procedures performed in an outpatient setting. eviCore Radiation Therapy Program Platform Improvements Providers who have previously submitted Radiation Therapy prior authorization requests to eviCore on the legacy CareCore National (ISAAC) utilization management system will notice several differences in authorizations approved via the ImageOne platform. Proton beam therapy › eviCore’s unique education approach includes “predictive intelligence” technology, which provides nearly instant precertification approval in areas where a provider consistently practices within evidence-based guidelines. IRS 2555 2021-2022 - Fill and Sign Printable TemplateAbout Form 2555, Foreign Earned IncomeInternal RevenueInstructions for Form 2555 (2021)Internal Revenue ServiceInstructions for . This evidencebas- ed medical coverage policy has been developed by eviCore, Inc. Such techniques include: Conventional Isodose Planning, Complex 3D Conformal Intensity-Modulated Radiation Therapy (IMRT) Image-Guided Radiation Therapy (IGRT) Stereotactic Radiosurgery (SRS) Clinical Guidelines for Cardiac Implantable Devices (CID) V2. Singla: The American Society for Radiation Oncology (ASTRO) 1 appreciates the continued dialogue with evidence-based clinical CLINICAL GUIDELINES Oncology Imaging Guidelines Version 1. . Chanta Van Laanen, Dr. No need to install software, just go to DocHub, and sign up instantly and for free. These guidelines are not meant to be all-inclusive, purpose is to ensure that radiation therapy services provided to members are consistent with national guidelines, and reflected in eviCore healthcare’s Radiation Therapy Clinical eviCore has released clinical guideline updates for the Radiation Oncology program. 2024 Abbreviation Definition GOG Gynecologic Oncology Group GS Gleason score Gy Gray HA-WBRT Hippocampal-avoidance whole brain radiation therapy HDR High-dose rate IGRT Image-guided radiation therapy ILROG International Lymphoma Radiation Oncology Group IMRT Intensity-modulated radiation therapy eviCore has released clinical guideline updates for the Radiation Oncology program. com • To access the link, select “Medical Policy” under Tools and Resources, read and accept the Blue Cross Medical Policy Statement The program’s purpose is to ensure that radiation therapy services provided to members are consistent with national guidelines. 2023 Preface to the Radiation Oncology EviCore’s lab management solution reduces genetic testing costs and improves quality care by utilizing current test-specific medical policies and prior authorization. EviCore’s clinical worksheets and guidelines are available online 24/7: based on EviCore’s evidence-based clinical guidelines. 0 Effective January 1, 2021 eviCore healthcare Clinical Decision Support Tool Diagnostic. These guidelines include procedures eviCore does not review for Cigna. bluecrossmn. 815. There may be certain procedures or services that are considered investigational by the payor. 13M lives Effective 4/1/2021, EviCore no longer manages the following memberships for Radiology and Cardiology Utilization Management (UM) programs: EviCore healthcare and Meridian are expanding their partnership to include the These guidelines include procedures eviCore does not review for Cigna. diagnosis specific guideline. aspx [CLIENT] Radiation Therapy Skin Cancer Request For NON-URGENT requests, please complete this document for authorization along with any relevant clinical documentation requested within this document (i. What procedures will require preauthorization? 2D and 3D Conformal, Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT), Brachytherapy, Hyperthermia, Proton Beam Therapy, Intensity-Modulated Radiation Therapy 3 If the simulation occurred, but the treatment begins after July 1, 2019, will it need authorization? Yes, we require prior authorization for treatments that are scheduled on or after July 1, 2019. To request any additional assistance in accessing the guidelines, provide feedback or clinical evidence related to the evidence-based guidelines, please click here. These authorizations include approvals for the radiation technique, the number of fractions (treatments), the • Claims are received that do not align with National Billing Guidelines for Radiation Therapy. MUSCULOSKELETAL . If you would like to view all EviCore core guidelines, please type in "EviCore by Evernorth" as your health plan. Nov 13, 2024 · Specialized therapies such as chiropractic, acupuncture, and physical therapy are cost-effective and can provide improved outcomes for chronic pain patients. Jan 24, 2025 · There may be instances in which your health plan policies take precedence over the EviCore by Evernorth clinical guidelines. radiation therapy consultation, comparison plan, etc. Guideline updates will become effective September 1, 2021: Please review all guidelines when submitting a prior authorization request. eviCore will provide a medical necessity decision based on the treatment plan, plus any pertinent clinical Radiation Oncology Guidelines V1. Intensity modulated radiation therapy (IMRT) Tomotherapy . Key Updates: Radiation Oncology Guidelines v2. com Radiation Oncology Guidelines . If you have any questions, please reach out to your health plan. 1. Specific elements of an individual’s medical records commonly required to establish medical necessity include, but are not limited to: Recent (within 60 days) virtual or in-person Radiation Oncology consultation which includes a detailed history, physical examination and diagnosis What guidelines does eviCore healthcare use to render Medical Necessity Determinations? The program’s purpose is to ensure that radiation therapy services provided to members are Radiation Oncology Guidelines V1. If you would like to view all EviCore core worksheets, please type "EviCore by Evernorth" into your health plan. The program’s purpose is to ensure that radiation therapy services provided to members are consistent with national guidelines. Search by health plan name to view clinical worksheets. General Information 5 of 308 Radiation Oncology Guidelines . Such techniques include: Conventional Isodose Planning, Complex 3D Conformal Intensity-Modulated Radiation Therapy (IMRT) Image-Guided Radiation Therapy (IGRT) To access the eviCore Provider Portal, visit www. com Phone (all programs): 844-635-7224 Monday –Friday 7 AM –7 PM (local time) Fax Medical Oncology: 800-540-2406 Radiation Therapy: 866-699-8160 The eviCore Provider Portal is the easiest, most efficient way to request clinical reviews and check statuses. 2023 Radiation Oncology Clinical Appeal Documentation Requirements RO. Which members will EviCore manage for the Radiation Oncology program? eviCore will manage prior authorization for Health Net members who are enrolled in the following programs: • Medicare • Commercial Radiation Oncology Guidelines V1. 2024 Abbreviations v1. › eviCore’s unique education approach includes “predictive intelligence” technology, which provides nearly instant precertification approval in areas where a provider consistently practices within evidence-based guidelines. Stereotactic body radiation therapy (SBRT) Biology-guided Radiation Therapy (BgRT) Complex (77307) 3D conformal . can be found under the Clin-ical Worksheets link, by Typing in ‘EviCore healthcare’ as the Health Plan. (ASTRO) updated its evidence-based guidelines to recommend hypofractionation as the preferred regimen for women with invasive breast cancer receiving whole breast irradiation As exciting All solutions operate on a single platform . The main component of the Radiation Therapy Program is preauthorization for all radiation therapy services. more clinically impactful updates. eviCore. com RE: eviCore Peer Review Concerns Dear Dr. As of June 1, 2024, eviCore will no longer be What guidelines does eviCore healthcare use to render Medical Necessity Determinations? The Program’s purpose is to ensure radiation therapy services provided to members are consistent CLINICAL GUIDELINES Radiation Oncology Version 2. 24 Neutron Beam Therapy (800) 918-8924 www. 3 . Jul 18, 2023 · eviCore healthcare (eviCore) will begin accepting prior authorization requests for Radiation Oncology services on December 17, 2020 for treatments starting January 1, 2021 and after. Radiation therapy guidelines A treatment plan in which a radiation therapy technique is intended to be used to treat the patients diagnosis requires authorization. Please note that only some of the following example questions will need to be answered during the Intensity modulated radiation therapy (IMRT) Tomotherapy . 2024 CT CPT ® CT Pelvis with contrast 72193 CT Abdomen and Pelvis with contrast 74177 Bone Mineral Density CT, on or more sites, axial skeleton 77078 CT Guidance for Placement of Radiation Therapy Fields 77014 Unlisted CT procedure (for radiation planning or surgical software) 76497 CTA CPT ® eviCore’s Radiation Therapy clinical guidelines and PA code list are available on the Blue Cross website at providers. 0 Effective eviCore Radiation Oncology Coding Guidelines . Some information in this coverage policy may not apply to all benefit plans administered by Cigna. 13 Prior Authorization Outcomes Approved Requests: • Processed within 2 business days after therapy/radiation-therapy-tools-and-criteria. Will daily Image-guided radiation therapy (IGRT) be used? Pediatric Musculoskeletal Imaging Guidelines V1. Coding Guidelines. 2024 (Effective October 1, 2024) Please note that this is not a comprehensive list of updates, but rather are some of the . The work required for the 4DCT performed during simulation for 2020, 2021, 2022, and 2023 Image-Guided Radiation Therapy (IGRT). URGENT (same day) requests must be submitted by phone. Mark Leichter to learn more. When this occurs, the ordering provider can acceptthe alternative recommendation by building a new case. CLINICAL GUIDELINES Oncology Imaging Guidelines Version 1. Laura Beitz-Walters, and Dr. precedence over EviCore's guidelines. Please refer to the Cigna CPT radiation therapy, or surgery), including evaluation at the end of planned active treatment Unless otherwise stated in the diagnosis-specific guidelines, imaging for treatment response can be approved after every 2 cycles, which is usually ~6 weeks of Example: The reason for denial states in your letter states: Based on EviCore Radiation Therapy (RT) Guidelines Section: Radiation Therapy for Bone Metastases, we cannot approve this request. The eviCore Radiation Therapy Prior Authorization program is designed to review and approve a specific radiation therapy treatment plan. com under the Guidelines and Fax Forms section. Failure to provide all relevant information may delay the determination. Approval is based on clinically An eviCore Radiation Therapy pre-service authorization will include all pertinent radiation therapy services for a member’s entire episode of care. Providers are urged to obtain written instructions and requirements directly from each payor. Contouring for intensity modulated radiation therapy (IMRT), even when multiple image sets are referenced 3. Phone and fax numbers can be found on eviCore. Radiation therapy guidelines Liver Cancer, Selective Internal Radiation Therapy Physician Worksheet Lung Cancer, Small Cell Physician Worksheet EviCore's clinical guidelines are evidence-based and apply to the following categories of service for individuals Radiation therapy services: Complex 3D Conformal Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT) Image Guided Radiation Therapy (IGRT) Brachytherapy Hyperthermia Proton Beam Therapy Intensity-Modulated Radiation Therapy (IMRT) Neutron Beam Therapy and Radiopharmaceuticals An eviCore Radiation Therapy pre-service authorization will include all pertinent radiation therapy services for a member’s entire episode of care. Failure to provide all EviCore by Evernorth is pleased to provide prior authorization services for Clover Health for dates of service August 1, 2020 and beyond. If request is for total skin electron beam therapy (TSEBT), how many fractions will be rendered? See question #1c. 2022 Abbreviation Definition and Obstetrics GOG Gynecologic Oncology Group GS Gleason score Gy Gray HA-WBRT Hippocampal-avoidance whole brain radiation therapy HDR High-dose rate IGRT Image-guided radiation therapy ILROG International Lymphoma Radiation Oncology Group IMRT Intensity-modulated Intensity modulated radiation therapy (IMRT) Proton beam therapy Rotational arc therapy Tomotherapy Stereotactic body radiation therapy (SBRT) Electrons Number of fractions: _____ Number of fractions: _____ 7. 2023 CPT®Code(s) Definition Clinical Documentation 77014 (TC) CT for Treatment Planning As of 2014, code 77014 for CT acquisition is included in the simulation codes 77280-77290 and 77295 and should Feb 16, 2021 · Oxford Insurance Cardiology Program Frequently Asked Questions Page 3 of 4 400 BUCKWALTER PLACE BOULEVARD BLUFFTON, SC 29910 PH: 800. For all Radiation Therapy Procedures including: Sep 19, 2023 · documentation requested within this document (i. Biology-Guided Radiation Therapy (BgRT) A. Please submit the request for inpatient hospitalization to Network Health. Guidelines with substantive changes: • Breast Cancer • Brain Metastases • Image-Guided Radiation Therapy (IGRT) An eviCore Radiation Therapy pre-service authorization will include all pertinent radiation therapy services for a member’s entire episode of care. Scroll to the table of contents and locate the reason for denial Radiation Oncology Coding Manual V2. com Radiation Oncology Guidelines V1. For complete guideline updates, please refer to the . 2023 Abbreviations v2. These guidelines summarize definitions and appropriate use of several CPT® codes. 2024 Abbreviation Definition GOG Gynecologic Oncology Group GS Gleason score Gy Gray HA-WBRT Hippocampal-avoidance whole brain radiation therapy HDR High-dose rate IGRT Image-guided radiation therapy ILROG International Lymphoma Radiation Oncology Group IMRT Intensity-modulated radiation therapy EviCore will manage Radiation Therapy services for Health Net for Radiation Therapy treatments. Guidelines with substantive changes: • Bladder Cancer Brain Metastases • Breast Cancer Cancer of the Adrenal Gland A treatment plan in which a radiation therapy technique is intended to be used to treat the patient’s diagnosis requires authorization. 65M lives . 2024 Abbreviation Definition FIGO International Federation of Gynecology and Obstetrics GOG Gynecologic Oncology Group GS Gleason eviCore Radiation Oncology Coding Guidelines These guidelines summarize definitions and appropriate use of several CPT ® codes. Correct coding guidelines are based on ASTRO/ACR Radiation Therapy coding resources. Proton beam therapy . 0 ______________________________________________________________________________________________________ Please note the following: All information provided by the NCCN is “Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN 2021, eviCore healthcare began accepting prior authorization requests for select services with dates of service beginning on April 1, 2021. EviCore. 6580 EVICORE. 2022 Abbreviation Definition and Obstetrics GOG Gynecologic Oncology Group GS Gleason score Gy Gray HA-WBRT Hippocampal-avoidance whole brain radiation therapy HDR High-dose rate IGRT Image-guided radiation therapy ILROG International Lymphoma Radiation Oncology Group IMRT Intensity-modulated Effective Jan. zpp dsgiu bmkuq vfr qwdjr zkaiwx lrdlt boqzc aqu kgkno