Radiation Therapy Authorization Program

In an effort to help ensure that the radiation oncology therapy services provided to our members are consistent with nationally recognized clinical guidelines, Highmark has contracted with eviCore healthcare to provide medical necessity review and authorization where applicable for select radiation oncology therapy services.

Physician Worksheets

These worksheets include all clinical questions that are asked by eviCore during the initial authorization review regardless of whether your request is submitted via NaviNet or telephone. Reviewing the worksheet will help you prepare to answer the necessary questions during the authorization review.

Adrenal Esophagus Multiple Myeloma
Anal Canal Extracranial Oligometastases Non-Cancerous
Bile Duct Gallbladder Non-Hodgkins Lymphona
Bladder Gastric (stomach) Pancreatic
Bone Metastases Head and Neck Prostate
Bone Metastases, Xofigo Hepatobiliary Rectal
Brain Metastases Hodgkins Lymphoma Skin
Breast Kidney Soft Tissue Sarcoma
Primary CNS Lymphoma Liver Testicular
Primary CNS Neoplasm Liver SRT Treatment Urethral
Cervical Lung, Non-Small Cell Vulva
Endometrial Lung, Small Cell Other Cancer Types

Reference Materials

Last updated on 3/4/2019


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