937 Form

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Medical Policy Carelon (formerly AIM) Quality Care Cancer Program (Radiation Oncology) Policy Number: 937 BCBSA Reference Number: N/A Effective Date: July 1, 2021

Related Policies Carelon Quality Care Cancer Program CPT and HCPCS Codes (Radiation Oncology), #938 Table of Contents Overview ....................................................................................................................................................... 1 Policy and Coverage Criteria for Commercial and Medicare Advantage Products ...................................... 1 Requesting Prior Authorization Information through Carelon ....................................................................... 2 List of Retired Blue Cross Blue Shield of Massachusetts Radiation Oncology Medical Policies ................. 2 The following Radiation Oncology medical policy is managed by Blue Cross: ............................................ 2 Policy History ................................................................................................................................................ 3 Disclaimer...................................................................................................................................................... 3 References .................................................................................................................................................... 3

Overview
Effective July 1, 2021, Blue Cross Blue Shield of Massachusetts has delegated utilization management of outpatient radiation oncology services to Carelon Medical Benefits Management, an independent company, for Commercial and Medicare Advantage products.

The Radiation Oncology Quality Care Cancer Program requires prior authorization for outpatient radiation oncology treatments, per the medical necessity criteria reflected in the Carelon Medical Benefits Management Clinical Guidelines for Commercial and Medicare Advantage products.

The Carelon Medical Benefits Management Clinical Guidelines are based on peer-reviewed literature and recommendations from evidence-based research centers such as (but not limited to): the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN).

Policy and Coverage Criteria for Commercial and Medicare Advantage Products The Carelon Medical Benefits Management Clinical Guidelines include medical necessity criteria for the following Radiation Oncology services:

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• Brachytherapy, intensity modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) treatment guidelines
• Proton Beam Therapy Guidelines Requesting Prior Authorization Information through Carelon Medical Benefits Management
To request prior authorization for the following products: Commercial Managed Care (HMO and POS), Commercial PPO/EPO and Medicare Advantage HMO and PPO, please see instructions below:

Please request authorization with AIM in one of three ways:

1. Through a direct link on our Provider Central website at bluecrossma.com/provider. Log in and go to eTools and then to Carelon Medical Benefits Management. Click the Go Now button.
2. Go directly to the AIM ProviderPortal (registration is required) at www.providerportal.com Note: If you’ve already registered for the AIM ProviderPortal for Blue Cross Blue Shield of Massachusetts or another insurer, you won’t need to register again.

3. Call the AIM Contact Center (Monday – Friday, 8 a.m. – 6 p.m., ET) at 1-866-745-1783. List of Retired Blue Cross Blue Shield of Massachusetts Radiation Oncology Medical Policies The following Radiation Oncology medical policies will be retired effective July 1, 2021. These policies will no longer be available on the Blue Cross website as of this date. For medically necessary indications, see the Carelon Medical Benefits Management Clinical Guidelines for Radiation Oncology.

   Retired Medical Policies Policy Number Accelerated Breast Irradiation and Brachytherapy Boost After Breast-Conserving Surgery for Early-Stage Breast Cancer
   326 Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds
   175 Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
   437 Electronic Brachytherapy for Nonmelanoma Skin Cancer
   739 Endobronchial Brachytherapy
   091 High-Dose Rate Temporary Prostate Brachytherapy
   353 Hydrogel Spacer use During Radiotherapy for Prostate Cancer
   743 Intensity Modulated Radiation Therapy of the Prostate 090 Intensity Modulated Radiation Therapy: Central Nervous System Tumors
   910 Intensity-Modulated Radiation Therapy of the Breast and Lung 163 Intensity-Modulated Radiation Therapy: Abdomen and Pelvis
   165 Intensity-Modulated Radiation Therapy: Cancer of the Head and Neck or Thyroid
   164 Intracavitary Balloon Catheter Brain Brachytherapy for Malignant Gliomas or Metastasis to the Brain
   602 Intraoperative Radiation Therapy
   278 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
   277 The following Radiation Oncology medical policy is managed by Blue Cross:
   Blue Cross medical policy # 292 Radioembolization for Primary and Metastatic Tumors of the Liver prn.pdf
   • This policy is available on the Blue Cross website. • Prior authorization is not required from Blue Cross or Carelon Medical Benefits Management.

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Policy History Date Action 3/2023 AIM Specialty Health changed its name to Carelon Medical Benefits Management. 11/2022 Policy clarified. Policy 292 does not require authorization from Blue Cross or from AIM.
7/2021 Policy issued 7/1/2021. Effective 7/1/2021. Disclaimer
Coverage is subject to applicable benefit contract. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Member’s medical records must document that services are medically necessary for the care provided. Blue Cross Blue Shield of Massachusetts maintains the right to audit the services provided to our members, regardless of the participation status of the provider. All documentation must be available upon request. Failure to produce the requested information may result in denial or retraction of payment. References: Carelon Medical Benefits Management Clinical Guidelines for Radiation Oncology