Evicore to declare benign radiotherapy DEAD

[TheWallnerus]

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After supporting radiation for benign indications like osteoarthritis, plantar fasciitis, tendonitis, bursitis, etc., since Evicore guidelines first came out around 2010, come November 2026 Evicore clinical guidelines will state radiation is not necessary for any of these indications (except elbow epicondylitis?).

The future guidelines are here:

https://www.evicore.com/sites/default/files/clinical-guidelines/2026-06/Emblem_Radiation%20Oncology_V3.0.2026_Eff11.05.2026_Pub06.23.2026.pdf

In the meantime, call your congressmen, ASTRO, and Varian sales reps...

But my prediction is this will effectively kill being able to practice benign RT in the U.S.

 

[CaesarRO]

The irony is I'm old enough to remember that it was SDN members noticing osteoarthritis listed as a medically necessary in Evilcore Guidelines, quoting DEGRO, that got the whole thing off its feet in the United States

 

[Ray D. Ayshun]

After supporting radiation for benign indications like osteoarthritis, plantar fasciitis, tendonitis, bursitis, etc., since Evicore guidelines first came out around 2010, come November 2026 Evicore clinical guidelines will state radiation is not necessary for any of these indications (except elbow epicondylitis?).

The future guidelines are here:

https://www.evicore.com/sites/default/files/clinical-guidelines/2026-06/Emblem_Radiation%20Oncology_V3.0.2026_Eff11.05.2026_Pub06.23.2026.pdf

In the meantime, call your congressmen, ASTRO, and Varian sales reps...

But my prediction is this will effectively kill being able to practice benign RT in the U.S.

I recently had a patient with Dupuytren's that required prior auth for radiation. The auth company said they don't auth rt for benign conditions as it's not their purview. The insurance Co in turn said no prior auth was needed. They paid. Was a strange scenario. Anyway, ultimately Evicore is a speed bump and fighting to keep themselves relevant. I expect I'll have to put together a general form letter for appeals to the insurance company. Either way, I don't foresee this stopping RT for arthritis, try as they might. Just plan on appealing direct to insurance in every case should this not ultimately get deleted.

 

[TheWallnerus]

The irony is I'm old enough to remember that it was SDN members noticing osteoarthritis listed as a medically necessary in Evilcore Guidelines, quoting DEGRO, that got the whole thing off its feet in the United States

And DEGRO gives a level 1/class A recommendation for RT for plantar fasciitis.

EviCore cites DEGRO guidelines to claim plantar fasciitis is not med nec.

 

[medgator]

I dream of the day that site-neutral bundles help kill off protons and evilcore

 

[Gfunk6]

If you get the reference, good for you!

 

[SneakyBooger]

And still they consider RT for other conditions "medically necessary" such as epilepsy, Parkinson's, essential tremor, familial tremor.

When discussing SRS for benign conditions they state on P. 257:
"The success and excellent safety margin of SRS in many other clinical situations has led to exploration of its use in benign tumors and neurologic conditions which are refractory to medical treatment and would otherwise require surgical procedures with significant morbidity and possible mortality. The condition to be treated must be causing severe symptoms or pose a serious threat to function or life expectancy and have an expected benefit of stabilizing or improving the clinical state."

Seems the same reasoning would apply to arthritis.

 

[Palex80]

Looking forward to the RadOnc-Twitter-meltdown this will result into...

 

[FletchersGarb]

Specifically aimed at osteoarthritis, pp 200-201. 210. Wonder how community would respond.

 

[medgator]

Evilcore playbook for how IGRT was handled for years in the palliative setting.

OA starting to cost insurers money so let's declare it "medically unnecessary".

At least with IGRT you could argue it/get it approved for obese pts.

 

[SneakyBooger]

When discussing SRS for benign conditions they state on P. 257:
"The success and excellent safety margin of SRS in many other clinical situations has led to exploration of its use in benign tumors and neurologic conditions which are refractory to medical treatment and would otherwise require surgical procedures with significant morbidity and possible mortality. The condition to be treated must be causing severe symptoms or pose a serious threat to function or life expectancy and have an expected benefit of stabilizing or improving the clinical state."

Will put my take on this in my appeal letter, which I will also send a copy to the OIG and state insurance regulator for every single patient that gets denied. Should I send it to Morgan & Morgan?

As stated in Evicore's 2026 Radiation Oncology Guidelines for 2026 (https://www.evicore.com/sites/defau...ogy_V3.0.2026_Eff11.05.2026_Pub06.23.2026.pdf):
"The success and excellent safety margin of (LDRT) in many other clinical situations has led to exploration of its use in benign (orthopedic conditions) which are refractory to medical treatment and would otherwise require surgical procedures with significant morbidity and possible mortality. The condition to be treated must be causing severe symptoms or pose a serious threat to function or life expectancy and have an expected benefit of stabilizing or improving the clinical state."

I should and do confess that in the above paragraph I have intentionally corrected Evicore's flawed statement. The terms in parentheses are mine, not Evicore's. The above statement is found on page 257 of Evicore's 2026 Radiation Oncology Guidelines supporting Evicore's declaration that radiation to treat benign neurological conditions, such as epilepsy, Parkinson's, essential tremor, familial tremor, is medically necessary. Interestingly, the use of radiation in the above neurological conditions is an area where there exists exponentially less evidence of any benefit and is of much lower quality compared to LDRT for inflammatory orthopedic conditions. Furthermore, the doses of radiation used in those benign neurological conditions and the toxicity risks are far far higher and come with the potential for a devastating negative impact on a patient's quality of life for the remainder of their life, something not seen with LDRT for joint inflammation. Actually, for LDRT it is quite the opposite.

In direct contrast to Evicore's guidelines prior to 2026 wherein they stated LDRT for osteoarthritis was medically necessary, without explanation Evicore declared it not medically necessary in 2026.

Evicore must reconcile these egregious discrepancies immediately. Until they do so, based upon their own published display of flawed reasoning, their argument that LDRT for arthritis is not medically necessary is unfounded and illogical. Frankly, I find this carelessness negligent and denying the safest treatment available to alleviate the suffering of thousands and thousands of arthritis patients leads to an unarguable harm.

 

[metallica81788]

How can one company unilaterally just do something like this and it just gets accepted as true? Absurd that this can exist in our system.

 

[TheWallnerus]

How can one company unilaterally just do something like this and it just gets accepted as true? Absurd that this can exist in our system.

Company buttressed by the confidence that the rad onc community can’t and/or won’t do anything about it

 

[Ray D. Ayshun]

to whom do you report medicare replacement plans? my state insurance commission said they don't deal with those plans.

 

[drowsy12]

@WildRivers any insights on whether payors are going to be using their middle men deniers to start pushing this more broadly? I'm a bit surprised as I can't imagine this is that much money but I guess it's enough to make a dent on someone's radar. I am sure with AI tracking, any big delta is noted, even if the absolute value is low.

 

[SneakyBooger]

to whom do you report medicare replacement plans? my state insurance commission said they don't deal with those plans.

In my state it appears to be the state Dept of Financial Services

 

[WildRivers]

@WildRivers any insights on whether payors are going to be using their middle men deniers to start pushing this more broadly? I'm a bit surprised as I can't imagine this is that much money but I guess it's enough to make a dent on someone's radar. I am sure with AI tracking, any big delta is noted, even if the absolute value is low.

Yeah, our company believes it to be medically necessary. But, Evicore is the market leader unfortunately. This is kind of absurd, with the use of it and the fact that it is a plenary this year. Can be debate on this, but with positive RCTS, I don't know if it is correct to call it entirely medically unnecessary.

I'm not sure what percentage of radonc spending is LDRT - I agree that it can't be very much.

This could be a big problem.

 

[NotMattSpraker]

This is unfortunate.

In the linked PDF they use it as an example for 77402. So will they cover it at that level or not at all?

 

[OTN]

This is one of the reasons why we need radoncs to be aggressive champions of our modality.

 

[DrProtonX]

This is exactly why we need to find a way to offer RT as a cash only service the way some other specialties does for their services. I’m sure there will be plenty of people willing to pay few thousand to alleviate their pain. I know it might not sound the most ethically noble way… but as some say, we need to keep the lights on

 

[OTN]

This is exactly why we need to find a way to offer RT as a cash only service the way some other specialties does for their services. I’m sure there will be plenty of people willing to pay few thousand to alleviate their pain. I know it might not sound the most ethically noble way… but as some say, we need to keep the lights on

There is nothing ethically wrong with offering a service to someone at a price they are willing to pay. I have had patients pay cash for all kinds of radonc services for various reasons. (I.E. a veterinarian who didn't have health insurance by choice paid cash for his H+N treatment). It would be ethically wrong to expect radoncs and their staffs to provide services for free.

 

[SneakyBooger]

This is exactly why we need to find a way to offer RT as a cash only service the way some other specialties does for their services. I’m sure there will be plenty of people willing to pay few thousand to alleviate their pain. I know it might not sound the most ethically noble way… but as some say, we need to keep the lights on

My primary referrer, an ortho, agrees and has encouraged our center to come to a decision as to what that price should be. So far, admin has been unsuccessful at doing so.

 

[taserlaser]

We are considering opening up a local clinic for exactly this with an xstrahl unit. We have been told on no uncertain terms we can’t offer this in the cancer centers and so are working on our business plan which at least at first estimates seem favourable at the moment.

 

[BobbyHeenan]

We are considering opening up a local clinic for exactly this with an xstrahl unit. We have been told on no uncertain terms we can’t offer this in the cancer centers and so are working on our business plan which at least at first estimates seem favourable at the moment.

It’s so crazy to see how different hospitals handle this.

My center is pushing us to start ramping this service line up. We’ve been passively doing cases as they come, but no advertisement or anything, just getting what comes in from PCPs .

Of course it doesn’t pay great, but assuming you have the bandwidth why would they not wanting you treating these patients at the cancer center?

 

[WildRivers]

It’s so crazy to see how different hospitals handle this.

My center is pushing us to start ramping this service line up. We’ve been passively doing cases as they come, but no advertisement or anything, just getting what comes in from PCPs .

Of course it doesn’t pay great, but assuming you have the bandwidth why would they not wanting you treating these patients at the cancer center?

taser is from canada. capacity differences

i like cash pay idea.

 

[BobbyHeenan]

taser is from canada. capacity differences

i like cash pay idea.

Ah (or Eh), that makes sense.

 

[WildRivers]

Legit question

Do any of you find it interesting / stimulating to see OA patients? Its not unpleasant by any means, but I don't particularly enjoy it.

 

[BobbyHeenan]

Legit question

Do any of you find it interesting / stimulating to see OA patients? Its not unpleasant by any means, but I don't particularly enjoy it.

Same.

I pride myself on being a full-service oncologist for my cancer patients. Managing work up, symptom management, etc. being actively involved in decision making and steering their care.

I am 100% just a technician for arthritis though. No meds from me, defer to other docs , etc. Obviuosly I make the decisions for who is a candidate, etc. but I’m not messing with meds or being the point person for the arthritis.

I am fine with this though.

 

[OTN]

Legit question

Do any of you find it interesting / stimulating to see OA patients? Its not unpleasant by any means, but I don't particularly enjoy it.

I've had some patients with dramatic responses to LDRT for OA who have been very, very thankful, so I do find it rewarding. Plus, it's nice from time to time to be able to offer a treatment without the chance of significant SEs.

 

[WildRivers]

Makes sense - with your volume this would be welcome break. For me, there are weeks where it's 50/50 benign vs cancer.

It is amazing when they respond. Such grateful patients. Very different than prostate / breast - who were never symptomatic to begin with. And basically you gave them some toxicity for something invisible to them.

 

[TheWallnerus]

plantar fasciitis deserves mention/umbrage here as much (or more?) than OA

 

[hippocratic57]

We need the LoRD KnEA trial to publish out ASAP.

 

[medgator]

There is nothing ethically wrong with offering a service to someone at a price they are willing to pay. I have had patients pay cash for all kinds of radonc services for various reasons. (I.E. a veterinarian who didn't have health insurance by choice paid cash for his H+N treatment). It would be ethically wrong to expect radoncs and their staffs to provide services for free.

💯

I've treated international and self insured pts with the Medicare fee schedule when they are paying cash. Being the low cost provider in the area does not mean our services are for free

 

[medgator]

Same.

I pride myself on being a full-service oncologist for my cancer patients. Managing work up, symptom management, etc. being actively involved in decision making and steering their care.

I am 100% just a technician for arthritis though. No meds from me, defer to other docs , etc. Obviuosly I make the decisions for who is a candidate, etc. but I’m not messing with meds or being the point person for the arthritis.

I am fine with this though.

Same. Have to have boundaries on what/how you want to practice otherwise you could get really busy/inundated quickly IMO.

I give ADT and place fiducials under trus which I hire 3rd party but I have zero interest in prescribing oral oncolytics/2nd gen anti androgens but apparently many GU and rad oncs do if they own a dispensing pharmacy. I just find it easier to refer out. Just like other specialties find a low threshold to refer over for primary malignancies, second opinions, mets etc. Want to keep it xrt focused

 

[SneakyBooger]

just saw a patient whose bilateral knee pain went from 9/10 to 2/10...

 

[rymd]

So Evicore ignores DEGRO, and ACR, and supports their decision with a VA policy statement from 2024 Radiation Therapy for Benign Conditions: A Systematic Review that says nothing (peruse at your own leisure)
And a single meta-analysis published last year with 3 citations, that basically pulled the negativge trials we know well and reported on it.
Here is their conclusion- summarized via ChatGPT "This meta-analysis does not show that LDRT is inappropriate for osteoarthritis. Instead, it concludes that the available evidence is limited and heterogeneous, with differences in patient populations, joints treated, radiation regimens, and follow-up periods making firm conclusions difficult. The authors suggest that earlier-stage OA patients may benefit more than those with advanced disease and emphasize the need for larger, well-designed randomized trials to better define the role of LDRT."
A further quote from the same article "There are NO good quality studies for any treatment of advancing OA to quote from the same paper "It is also important that despite extensive investigation, no treatment has been effective enough to affect OA disease course"

Yet their last paragraph reads like every other paper that more studies are needed and that is what Evicore quotes? they didn't even read the paper.

So this is purely a money/control grab by Evicore and if ASTRO doesn't fight this then... cash business it is.

 

[Gfunk6]

So this is purely a money/control grab by Evicore...

 

[Ray D. Ayshun]

So Evicore ignores DEGRO, and ACR, and supports their decision with a VA policy statement from 2024 Radiation Therapy for Benign Conditions: A Systematic Review that says nothing (peruse at your own leisure)
And a single meta-analysis published last year with 3 citations, that basically pulled the negativge trials we know well and reported on it.
Here is their conclusion- summarized via ChatGPT "This meta-analysis does not show that LDRT is inappropriate for osteoarthritis. Instead, it concludes that the available evidence is limited and heterogeneous, with differences in patient populations, joints treated, radiation regimens, and follow-up periods making firm conclusions difficult. The authors suggest that earlier-stage OA patients may benefit more than those with advanced disease and emphasize the need for larger, well-designed randomized trials to better define the role of LDRT."
A further quote from the same article "There are NO good quality studies for any treatment of advancing OA to quote from the same paper "It is also important that despite extensive investigation, no treatment has been effective enough to affect OA disease course"

Yet their last paragraph reads like every other paper that more studies are needed and that is what Evicore quotes? they didn't even read the paper.

So this is purely a money/control grab by Evicore and if ASTRO doesn't fight this then... cash business it is.

I suspect it's meant to get ASTRO to push back, and then to agree it's a 77402 with no imaging. The end result of this will be sporadic closure of the strait of hormuz.

 

[emt409]

ASTRO, ACRO, Varian, and others are all planning on pushing back. Ultimately a grassroots-funded attorney filing for an injunction may work the quickest though....

 

[FletchersGarb]

ASTRO, ACRO, Varian, and others are all planning on pushing back. Ultimately a grassroots-funded attorney filing for an injunction may work the quickest though....

What sort of patient harm can they allege, though?

 

[emt409]

What sort of patient harm can they allege, though?

Standard IANAL disclosure, but I would assume loss of previously held and contracted benefits is part of it....

 

[WildRivers]

Has there ever been a court order to make a payor cover a treatment ?

 

[medgator]

Has there ever been a court order to make a payor cover a treatment ?

Blue Cross is Required to Pay for Proton Beam Therapy to Treat Throat Cancer | South Florida Proton Therapy Institute

According to a ruling upheld by the Fifth Circuit, Blue Cross is required to pay for proton beam therapy to treat throat cancer. The district court’s ruling that Louisiana Health Service &

sfpti.com

 

[WildRivers]

Well .. there is more evidence for this than protons so looks like should be okay !

 

[TheWallnerus]

Payors having to pay for things doctors think should be covered would be way more of a thing if doctors actually banded together and put legal and public pressure on payors whenever they tried “shenanigans”

 

[grenz]

Payors having to pay for things doctors think should be covered would be way more of a thing if doctors actually banded together and put legal and public pressure on payors whenever they tried “shenanigans”

This is what a professional society is for. And to my knowledge ASTRO has been doing just this with Evicore since the new codes came out. I’ve noticed ASTRO is putting out more media releases in response to negative lay press articles since Kavadi took over as CEO.