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Radiation Therapy for Pancreatic Cancer

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Radiation Therapy for Pancreatic Cancer CLINICAL GUIDELINES Radiation Therapy V2.0.2019 Effective July 1, 2019 Clinical guidelines for medical necessity review of radiation therapy services. © 2019 eviCore healthcare. All rights reserved. Radiation Therapy Criteria V2.0.2019 Table of Contents Hyperthermia 6 Image-Guided Radiation Therapy (IGRT) 9 Neutron Beam Therapy 13 Proton Beam Therapy 15 Radiation Therapy for Anal Canal Cancer 57 Radiation Therapy for Bladder Cancer 60 Radiation Therapy for Bone Metastases 63 Radiation Therapy for Brain Metastases 68 Radiation Therapy for Breast Cancer 76 Radiation Therapy for Cervical Cancer 87 Radiation Therapy for Endometrial Cancer 94 Radiation Therapy for Esophageal Cancer 101 Radiation Therapy for Gastric Cancer 106 Radiation Therapy for Head and Neck Cancer 109 Radiation Therapy for Hepatobiliary Cancer 113 Radiation Therapy for Hodgkin’s Lymphoma 119 Radiation Therapy for Kidney and Adrenal Cancer 123 Radiation Therapy for Multiple Myeloma and Solitary Plasmacytomas 125 Radiation Therapy for Non-Hodgkin’s Lymphoma 129 Radiation Therapy for Non-malignant Disorders 134 Radiation Therapy for Non-Small Cell Lung Cancer 152 Radiation Therapy for Oligometastases 163 Radiation Therapy for Other Cancers 173 Radiation Therapy for Pancreatic Cancer 174 Radiation Therapy for Primary Craniospinal Tumors and Neurologic Conditions 180 Radiation Therapy for Prostate Cancer 188 Radiation Therapy for Rectal Cancer 197 Radiation Therapy for Skin Cancer 200 Radiation Therapy for Small Cell Lung Cancer 208 Radiation Therapy for Soft Tissue Sarcomas 211 Radiation Therapy for Testicular Cancer 217 Radiation Therapy for Thymoma and Thymic Cancer 220 Radiation Therapy for Urethral Cancer and Upper Genitourinary Tract Tumors 224 Radiation Treatment with Azedra 226 Radiation Treatment with Lutathera 229 Radioimmunotherapy with Zevalin 234 Selective Internal Radiation Therapy 245 ______________________________________________________________________________________________________ © 2019 eviCore healthcare. All Rights Reserved. Page 1 of 250 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com Radiation Therapy Criteria V2.0.2019 Please note the following: CPT Copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. ______________________________________________________________________________________________________ © 2019 eviCore healthcare. All Rights Reserved. Page 2 of 250 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com Radiation Therapy Criteria V2.0.2019 Please note the following: All information provided by the NCCN is “Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™)©2018/2019 National Comprehensive Cancer Network. The NCCN Guidelines™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org.” ______________________________________________________________________________________________________ © 2019 eviCore healthcare. All Rights Reserved. Page 3 of 250 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com Radiation Therapy Criteria V2.0.2019 Dear Provider, This document provides detailed descriptions of eviCore’s basic criteria (also known as clinical guidelines) for radiation therapy arranged by diagnosis. They have been carefully researched and are continually updated in order to be consistent with the most current evidence-based guidelines and recommendations for the provision of radiation therapy from national medical societies and evidence-based medicine research centers. In addition, the criteria are supplemented by information published in peer-reviewed literature. Our health plan clients review the development and application of these criteria. Every eviCore health plan client develops a unique list of CPT codes or diagnoses that are part of their radiation therapy utilization management programs. Health Plan medical policy supersedes the eviCore criteria when there is conflict with the eviCore criteria and the health plan medical policy. If you are unsure of whether or not a specific health plan has made modifications to these basic criteria in their medical policy for Radiation Therapy please contact the plan or access the plan’s website for additional information. While eviCore encourages participation in clinical trials when consistent with each health plan’s policies, we want to clarify our position on the use of such standard arms outside of the research setting. The use of a control arm or standard arm in a Phase III clinical trial does not necessarily mean that other standard treatment techniques are not equally effective. Examples of multiple “standard” arms can easily be found in the treatment of prostate cancer where Intensity-Modulated Radiation Therapy (IMRT), 3-Dimensional (3-D), low dose implant or High Dose Rate (HDR) can be equally effective or breast cancer where standard whole breast fractionation or hypo-fractionation can be used. Indeed, national criteria such as National Comprehensive Cancer Network ______________________________________________________________________________________________________ © 2019 eviCore healthcare. All Rights Reserved. Page 4 of 250 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com Radiation Therapy Criteria V2.0.2019 (NCCN) and American College of Radiology (ACR) Appropriateness Criteria often suggest more than one radiation technique. It is eviCore’s process to apply evidence-based criteria to the particular clinical characteristics in evaluating a case, and to certify the most appropriate regimen/modality. This regimen/modality may match one that is used as a “standard arm” in a federally funded clinical trial, or it may be one that is considered an “alternate standard”. The alternate standard will be one supported by nationally published guidelines such as the NCCN, ACR Appropriateness Guidelines, or American Society for Radiation Oncology (ASTRO) Evidence- Based Guidelines, or supported by other acceptable peer-reviewed publications. As such, eviCore will not automatically certify a case based solely on the fact that it matches the standard (control) arm of a clinical trial. This concept applies also to regimens/modalities listed by the NCCN or ACR as “acceptable” treatments for specific disease sites. Rather, we commit to working with the providing Radiation Oncologist to certify the most appropriate regimen/modality for a particular case. eviCore healthcare works hard to make your clinical review experience a pleasant one. For that reason, we have peer reviewers available to assist you should you have specific questions about a procedure. For your convenience, eviCore’s Customer Service support is available from 7 a.m. to 7 p.m. Our toll free number is (800) 918-8924. Gregg P. Allen, M.D. FAAFP EVP and Chief Medical Officer ______________________________________________________________________________________________________ © 2019 eviCore healthcare. All Rights Reserved. Page 5 of 250 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com Radiation Therapy Criteria V2.0.2019 Hyperthermia POLICY I. The use of hyperthermia and concurrent radiation therapy treatment is medically necessary for any of the following: A. Superficially recurrent melanoma B. Chest wall recurrence of breast cancer C. Recurrent cervical lymph nodes from head and neck cancer Treatment of the above conditions will be approved in the absence of both of the following: D. Metastatic disease for which chemotherapy or hormonal therapy is being given concurrently or planned E. Evidence of tumor recurrence exceeding 4 cm in depth When hyperthermia is indicated, no more than 10 hyperthermia treatments delivered twice weekly at 72-hour intervals should be utilized. II. The use of intraluminal, endocavitary, interstitial, regional deep tissue hyperthermia exceeding 4 cm in depth, and whole body hyperthermia is considered experimental, investigational, or unproven (EIU) Key Clinical Points After initial enthusiasm for the use of hyperthermia in the late 1970s, interest waned with the publication of studies showing little or no benefit in the mid-1980s. Later review of the negative findings disclosed that the critical temperature necessary for hyperthermic cell death, 42 to 43 degrees centigrade (C), was either poorly measured or poorly maintained in these studies. Point measurements rather than volume mapping of thermal gradients were relied upon in planning these hyperthermia studies. Renewed interest in the use of hyperthermia began to emerge in both Europe and the United States (US) in the 1990s. Research from Duke University, Northwestern University, University of Southern California, Stanford University, Washington University, as well as centers in Holland, Germany, Norway, Austria, Italy, and Switzerland have contributed substantially to the emergence of hyperthermia as a useful treatment modality when combined with radiation therapy. Currently, in the US, the Food and Drug Administration (FDA) has approved hyperthermia for use in the treatment of cancer when combined with radiation therapy for the “…palliative management of certain solid surface and subsurface malignant tumors (i.e. melanoma, squamous or basal cell tumors, adenocarcinoma, or sarcoma) that are progressive
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