Capital Health Plan has a partnership with Carelon Medical Benefits Management to provide utilization management for our Radiation Oncology Program to ensure clinically appropriate quality of care in the utilization of these services.
Under this program, Capital Health Plan requires prior authorization through Carelon Medical Benefits Management for the following Radiation Oncology services:
- 2D conventional and 3D conformal radiation therapy
- Proton beam therapy
- Intensity-modulated radiation therapy (IMRT)
- Intraoperative radiation therapy (IORT)
- Stereotactic body radiotherapy (SBRT)
- Stereotactic radiosurgery (SRS)
- Fractionation in bone metastases, non-small cell lung cancer, and breast cancer when requesting external beam radiation therapy (EBRT) and intensity-modulated radiation therapy (IMRT)
- Image-guided radiation therapy (IGRT)
- Special procedures and consultations associated with treatment planning (CPT® codes 73370 and 77470)
For more information, please review Carelon Medical Benefits Management's Commercial Clinical Guidelines or Medicare Clinical Guidelines. For direct access to Carelon Medical Benefits Management’s doctor/provider portal, please visit carelon.com.