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Health Plans | Utilization Management

Radiation Oncology

Part of EviCore’s Comprehensive Oncology suite, our Radiation Oncology solution uses the most up-to-date evidence-based clinical guidelines from peer-reviewed literature, professional societies, and leading cancer physician experts to ensure that patients achieve optimal clinical and financial outcomes.

Our solution directs oncology physicians to the best treatment options for each patient, based on their unique diagnosis, medical history, pathology, prior therapy, functional status, and disease severity. We also ensure payment integrity by reviewing the appropriateness and accuracy of billed claims.

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The U.S. population is skewing older and cancer cases are on the rise. The number of patients undergoing active treatment for cancer has never been higher, the complexity of therapy options is proliferating, and patients are being treated for longer periods of time. Meanwhile, cancer treatment remains a heavy financial burden.

Unfortunately, many patients do not receive a treatment plan consistent with current medical evidence. We see requests for:

  • Radiation treatment techniques without clinical evidence for specific cancer types
  • More costly therapy without evidence of superior outcomes
  • A greater number of treatment sessions than is necessary to achieve the best result

As well, the growing complexity of billing and coding guidelines for radiation oncology services leads to billing errors, resulting in incorrect payments and avoidable spending.

~90 million
adults aged 65+ in U.S. population
by 2050, vs. 46 million today1

Nearly 17 million
Americans are battling cancer today;
1.9 million new diagnoses in 20212

of cancer patients will receive
radiation treatment during their illness3



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Ensures Appropriate Utilization

EviCore evaluates the use of radiation therapy by addressing the appropriateness of the technology, treatment plan goals, care and costs. We rely on proprietary but publicly available clinical guidelines developed and continuously updated based on evidence from peer-reviewed literature, NCCN®, professional societies such as the American Society of Radiation Oncology (ASTRO®) and the American Society of Clinical Oncology (ASCO), and nationally recognized academic- and community-based board-certified radiation oncologists.

Aligns with ASTRO Choosing Wisely Initiatives4
Promotes patient care supported by the best evidence
while considering the financial impact of treatment


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Minimizes Time Spent by Providers

Our solution uses dynamic technology that minimizes provider administrative time by capturing only the necessary, clinically relevant information to connect patients to the care they need. In many cases, one authorization enables the entire treatment regimen with a single clinical review and ongoing payment management.

4 minutes
for providers to receive approval for
a complete episode of care

50 to 90% fewer
provider intake questions

20% fewer
clinical reviews and peer-to-peer consultations


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Delivers Value Through Episode of Care

EviCore works with health plans to identify providers that may be open to an episodic, value-based arrangement. We use our clinical and funding model expertise to negotiate an episodic payment arrangement that is fair to participating providers, allows for clinical and financial complexity, increases point-of-decision autonomy for providers, and delivers value to the plan and its members.




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Leverages our Expertise

Our medical directors are all board-certified radiation oncologists with specific experience in the development and use of clinical guidelines in community and academic practice settings. In addition, we employ doctors of pharmacy, medical geneticists, pathologists, oncology nurses, and genetic counselors who contribute to holistic patient care.



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Includes Payment Integrity for Claims

EviCore can also combine the coding and billing of the 140+ CPT codes to simplify reimbursement of radiation oncology services. Our post-service, pre-payment review claims management model can:

  • Reduce client capital expenditure required for claims system configuration
  • Increase solution efficacy by incorporating “end-to-end” management
  • Optimize authorization matching to the modifier/sub-CPT code level, eliminating the need for client IT resources to load authorization extract files
  • Apply correct coding/bundling edits, reducing waste and rework
  • Apply complex rules on code sets across EviCore solutions/modalities, ensuring accurate payment and optimal client savings

85,000 rules
applied to ensure health plans and patients
are responsible for only authorized claims.




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Improves Outcomes and Savings

Our solution offers the solution for a positive outcome and avoidance of the unnecessary costs and side effects associated with inappropriate health services, such as protracted therapy and avoidable emergency room visits and hospitalizations.

The success of our solution in promoting evidence-based cancer treatment and reducing wasteful spending has been repeatedly validated among local and national health plan clients around the country.

Up to 20% reduction
in radiation therapy cost, while
keeping denials under 5%



Frequently Asked Questions

EviCore’s clinical worksheets, request forms, and guidelines are available online 24/7. https://www.evicore.com/provider/clinical-guidelines

Medical necessity review for radiation therapy requests for all cancerous and non-cancerous indications. Treatment techniques can include (but are not limited to) the following: 

  • 3-D conformal radiation therapy
  • Intensity-modulated radiation therapy (IMRT)
  • Stereotactic radiosurgery/stereotactic body radiation therapy (SRS/SBRT)
  • Brachytherapy (low dose rate and high dose rate)
  • Radiopharmaceuticals
  • Proton beam therapy
  • Post-service, pre-payment, claims review

EviCore’s has been managing radiation oncology since 2009. Our Radiation Oncology solution operates in all 50 states and supports millions of Commercial, Medicare, and Medicaid members. We partner with many national, regional, and local health plans across the country.

Radiation Oncology Insights
Clinical Expertise

Prior to joining EviCore healthcare, I had the privilege of spending over a decade caring for patients with cancer. During this time, I observed the field of oncology evolve rapidly with technological advancements that have helped prolong, and in many cases, cure cancer. However, clinical evidence does not always keep up with technology and sometimes the adoption of unproven forms of treatment can create financial toxicity for patients without a gain in clinical benefit. As such, it is critical to ensure that treatments and technologies are appropriately used for the right patient at the right time while being supported by published evidence and national guidelines. At EviCore healthcare, we put patient care first and, in collaboration with our clients, oncology societies, and physicians, we lay the foundation for positive patient outcomes.

Dr. Rajanish Singla Chief, Radiation Oncology
Board-Certified Radiation Oncologist

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