CurrentAnthemPolicy N/A

Expansion of precertification requirements for radiation therapy fractions (EBRT/IMRT) — NSCLC

Expands precertification requirements to include radiation therapy fractions for non-small cell lung cancer patients receiving EBRT or IMRT for Anthem local members; excludes FEP, Medicaid, Medicare Advantage, and Medicare Supplemental plans. Describes submission via AIM (Availity or call center) and verification using member ID or Anthem resources.

Policy Summary

PayerAnthem

PolicyExpansion of precertification requirements for radiation therapy fractions (EBRT/IMRT) — NSCLC

Policy CodePolicy N/A

Change TypeExpanded precertification (added diagnosis)

Effective DateOct 31, 2016

Next Review Date

Key ActionSubmit precertification requests for NSCLC EBRT/IMRT fractions via AIM (Availity portal or AIM call center).

SourceLink

POLICY UPDATE CHANGES

Precertification requirements for radiation therapy fractions are expanded to include non-small cell lung cancer diagnoses for covered individuals receiving EBRT or IMRT.

Oct 31, 2016effective date for expanded precertification

2 business daysretrospective requests accepted if within

877-291-0366AIM call center

800-676-2583Verification number

Coverage Criteria

Expanded precertification for NSCLC EBRT/IMRT

Precertification is required when ALL of the following apply:

Applicability

Diagnosis: Non-small cell lung cancer diagnosis
Explicitly added to fraction/unit precertification
Service: External Beam Radiation Therapy (EBRT) or Intensity Modulated Radiation Therapy (IMRT) fractions/units
Fractions (units) are the target of expanded precertification
Date of service: Services with date of service on or after October 31, 2016
Members undergoing treatment on October 31, 2016 are not impacted if already in treatment

Policy Summary

PayerAnthem

PolicyExpansion of precertification requirements for radiation therapy fractions (EBRT/IMRT) — NSCLC

Policy CodePolicy N/A

Change TypeExpanded precertification (added diagnosis)

Effective DateOct 31, 2016

Next Review Date

Key ActionSubmit precertification requests for NSCLC EBRT/IMRT fractions via AIM (Availity portal or AIM call center).

SourceLink

On This Page

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Pre-certification requirements do not apply to the following plans: Federal Employee Program (FEP), Medicaid, Medicare Advantage, or Medicare Supplemental plans. Verify whether pre-certification is required for a specific member by calling the pre-certification number on the back of the member's ID card or by consulting Anthem's Pre-certification Quick Reference Guide.

Radiation therapy that is performed as part of an inpatient admission will continue to be reviewed through Anthem's inpatient precertification process; the expanded outpatient Radiation Therapy Program precertification requirements do not replace inpatient review workflows.

Members who are already undergoing radiation therapy on October 31, 2016 will not be impacted by the expanded precertification requirements. The enhanced precertification requirement applies to members who begin treatment on or after October 31, 2016.

Coding and Claims

Affected diagnoses/procedures mentionedmixed

No codes listed

Retrospective submission window

Retrospective submission windowRetrospective precertification requests received more than 2 business days after the date of service will not be accepted by AIM for precertification review

Accepted retrospective windowRequests received within 2 business days after the date of service may be submitted for precertification review

Post-service reviewPost-service clinical review for requests received after the 2-business-day window will be handled by Anthem according to the terms of the applicable health benefit plan and/or provider agreement

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Effective October 31, 2016, precertification (prior authorization) is required for radiation therapy fractions (units) for non-small cell lung cancer patients receiving External Beam Radiation Therapy (EBRT) or Intensity Modulated Radiation Therapy (IMRT). This program is managed by AIM Specialty Health on behalf of Anthem.

Applies to Anthem local members who currently require precertification for non-emergency outpatient radiation therapy.
Does not apply to Federal Employee Program (FEP), Medicaid, Medicare Advantage, or Medicare Supplemental plans.

Note

Submission and Verification Instructions

Submission and Verification Instructions — Ordering and servicing physicians must submit precertification requests to AIM. Requests may be submitted online via the AIM portal, via Availity (www.availity.com), or by phone to the AIM Specialty Health Call Center at 877-291-0366. To determine if precertification is required for a specific member, call the number on the back of the member's ID card or check Anthem's Pre-certification Quick Reference Guide online.

Access AIM directly or via Availity Web Portal.
Call AIM Specialty Health Call Center: 877-291-0366.
Pre-Certification Quick Reference Guide available on anthem.com (Provider > select Colorado > Medical Policy, Clinical UM Guidelines, and Pre-cert Requirements).

Denial Risk

Late Submission Denial Risk

Late Submission Denial Risk — Retrospective precertification requests received more than 2 business days after the date of service will not be accepted by AIM for precertification review. Post-service clinical review, if requested, will be handled by Anthem according to the terms of the member's health benefit plan and/or provider agreement.

Retrospective requests >2 business days after date of service will not be accepted by AIM for precertification.

Background

In this policy, fractions (units) refer to the individual treatment sessions administered during External Beam Radiation Therapy (EBRT) or Intensity Modulated Radiation Therapy (IMRT). Anthem is expanding precertification to include these fractions for non-small cell lung cancer patients receiving EBRT or IMRT as part of its Radiation Therapy Program managed by AIM Specialty Health.

Definitions

Fractions / Units

DefinitionFractions (also referred to as units): individual radiation therapy treatment sessions.

ContextFractions/units are the target of expanded precertification for non-small cell lung cancer patients receiving EBRT or IMRT.

Term usageUsed in this policy to indicate the number of individual treatment sessions for External Beam Radiation Therapy (EBRT) or Intensity Modulated Radiation Therapy (IMRT).

EBRT / IMRT

EBRTExternal Beam Radiation Therapy (EBRT): a type of external beam radiation therapy technique referenced in the policy for which fractions/units precertification is expanded.

IMRTIntensity Modulated Radiation Therapy (IMRT): a type of external beam radiation therapy technique referenced in the policy for which fractions/units precertification is expanded.

ScopeBoth EBRT and IMRT for non-small cell lung cancer diagnoses are included in the expanded precertification requirements effective October 31, 2016.