CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Radiation Oncology Solutions Prior Authorization Program — Outpatient Radiation Therapy

Governs prior authorization and medical necessity review processes for outpatient radiation therapy treatments for Blue Cross Blue Shield of South Carolina members, managed by Evolent (Radiation Oncology Solutions Program). Affects radiation oncologists and cancer treatment facilities submitting authorization requests.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyRadiation Oncology Solutions Prior Authorization Program — Outpatient Radiation Therapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from Evolent (RadMD.com or phone) before initiating any outpatient radiation therapy, including modality and number of fractions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

180Authorization validity (days)

2015Program start

~2 biz daysMed nec turnaround

~1 biz dayModification turnaround

Coverage Criteria & Prior Authorization Rules

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Authorization and Medical Necessity — Outpatient Radiation Therapy

Covered when prior authorization and medical necessity review are completed and approved by Evolent for outpatient radiation therapy services.

Prior authorization required for: All cancers and other conditions for IMRT, Proton Beam, and SRS/SBRT; prior authorization is required for all outpatient radiation therapy modalities and the number of treatments/fractions for the course of treatment

See Radiation Oncology Utilization Review Matrix for CPT codes

Modalities subject to authorization: Brachytherapy (LDR, HDR, electronic), 2D conventional, 3D-CRT, IMRT, SRS/SBRT, Proton Beam Therapy (PBT), Intraoperative Radiation Therapy (IORT), Neutron Beam, Hyperthermia

Evolent provides utilization management services for all cancers and conditions

Authorization outcome: Once medical necessity determination is made, Evolent will provide physicians with confirmation of medical necessity review and approval specifying authorized treatment modalities and the number of treatments/fractions for the course of treatment

Authorization valid for 180 days from date of request

Exceptions / Continuity of Care

Exceptions to prior authorization

Exceptions: Inpatient radiation therapy authorized by the facility is not managed by Evolent; if a member began inpatient radiation therapy and continues subsequent outpatient treatment, or if a member began radiation therapy prior to Blue Cross Blue Shield of South Carolina coverage, outpatient radiation therapy will not require prior authorization for medical necessity review

Providers should fax a completed Radiation Therapy Treatment Notification (Transfer of Care) Form for each member to Blue Cross Blue Shield of South Carolina at 1-800-965-6286

Evolent provides utilization management for outpatient radiation therapy services but does not manage authorization for drugs associated with these services. Providers should obtain prior authorization for radiation therapy modalities and fractions through Evolent (RadMD or phone) as specified in the program.

If a request is denied as not medically necessary, Evolent will notify the ordering physician and include instructions for post-determination review. Providers may request a reconsideration by submitting new or additional clinical information via RadMD, phone, or fax using the case-specific fax cover sheet. Reconsideration must be initiated within 180 calendar days from the date of denial and must be done prior to filing a formal appeal. Peer-to-peer discussions are available and can be initiated by calling the number provided in the denial notice.

Codes, Authorization Validity, and Coding Matrix

Procedures requiring prior authorization (see matrix)mixedCovered

CPT codes listed on Radiation Oncology Utilization Review Matrix

Matrix on RadMD lists CPT codes requiring authorization for outpatient radiation therapy modalities

Authorization validity

Authorization validity period180 days from date of request (validity begins on date of request; if initial simulation occurs prior to request, validity is dated from date of initial simulation)

Start date usedDate of request (or date of initial simulation if simulation performed prior to request)

Scope of validityOne prior authorization number may cover the entire process of care; treatment must be completed within the 180-day validity window

Tracking and verificationProviders may verify authorization status online at RadMD.com or via Evolent's IVR using the authorization or tracking number

Payment riskPayment will be denied for procedures performed without a necessary prior authorization

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Prior authorization is required for all outpatient radiation therapy modalities and for the total number of treatments/fractions for the course of treatment. Submit the request to Evolent (RadMD.com or 1-866-500-7664) before the anticipated treatment start date. The prior authorization number is valid for 180 days from the date of request.

Applies to: Brachytherapy (LDR, HDR, Electronic), 2D, 3D-CRT, IMRT, SRS/SBRT, Proton Beam (PBT), IORT, Neutron Beam, Hyperthermia
One prior authorization number covers the entire process of care (no separate number per CPT code)
Payment will be denied for procedures performed without a necessary prior authorization

Documentation Required

Documentation Required for Medical Necessity Review

Documentation Requirements. Providers must supply the complete clinical treatment plan and supporting information when requesting prior authorization to ensure timely medical necessity review.

Provider contact: name and office phone number of the Radiation Oncologist planning and delivering therapy
Member information: name and ID number
Clinical details: primary disease site, TNM stage (T, N, M), treatment intent
Treatment plan: requested modality (initial and/or boost), total dose, number of fractions, guidance (IGRT, port films), simulation and anticipated treatment dates
Facility information: name of treatment facility
If information is incomplete, processing may be delayed — supply all requested data at initial submission

Step Therapy

No Step Therapy. Step therapy requirements are not applicable / none specified for radiation therapy prior authorization under this program.

Denial Risk

Denial Risk for Missing Authorization. Payment will be denied for procedures performed without a necessary prior authorization. Request prior authorization promptly and track the request via RadMD.com or Evolent's IVR.

Use the Evolent prior authorization or tracking number to monitor status online or via IVR
If modifications to an approved plan are needed (additional treatments), notify Evolent by calling 1-866-500-7664

Definitions

Medical necessity

Evolent medical necessity definitionA service that meets accepted standards of practice, is appropriate to the symptoms/diagnosis and intensity/setting, provides unique and essential information when diagnostic, is the lowest cost effective alternative, and is not furnished primarily for convenience.

Where to find guidelinesEvolent's Clinical Guidelines for Radiation Oncology Solutions services are available on RadMD.com under Online Tools/Clinical Guidelines.

Who requests reviewThe Radiation Oncologist determining the treatment plan is responsible for requesting medical necessity review for prior authorization determination.

ApplicabilityMedical necessity review requirements do not apply when Blue Cross Blue Shield of South Carolina is not the primary insurer.

OpenPayer

Radiation Oncology Solutions Prior Authorization Program — Outpatient Radiation Therapy

Coverage Criteria & Prior Authorization Rules

Codes, Authorization Validity, and Coding Matrix

What Providers Must Do

Program Background

Definitions