Radiation Therapy Management (RTM) - Blue Advantage

Blue Advantage is following eviCore Healthcare's Radiation Therapy policies for the following treatments:

  • Brachytherapy
  • Intensity-modulated Radiotherapy (IMRT) - Effective for dates of service October 1, 2016, and after, replaced by LCD* 36743.
  • Intraocular Radiation Therapy - Effective for dates of service February 26, 2018, and after, replaced by LCD* 34555.
  • Intraoperative Radiation Therapy (IORT) - For dates of service February 26, 2018, through April 3, 2018, follow Article 53414. Dates of service April 4, 2018, through September 23, 2018, follow eviCore. Dates of service September 24, 2018, and after follow LCD* 37779.
  • Lutathera® (lutetium Lu 177 dotatate) - Effective for dates of service November 1, 2018, and after, replaced by Article 56141.
  • Proton Beam Therapy - Effective for dates of service February 26, 2018, and after.
  • Radioembolization or Intra-Hepatic Microspheres (TheraSpheres®, SIRSpheres®)
  • Real-Time Intra-Fraction Motion Management During Radiation Therapy
  • Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) - Effective for dates of service February 26, 2018, and after.
  • Xofigo (Radium Ra 223 Dichloride) - Effective for dates of service February 26, 2018, and after, replaced by Article 54559.

 

 

*Local Coverage Determination