eviCore Radiation Therapy Clinical GuidelinesEffective 07/01/2019 - 07/14/2019

EviCore by Evernorth · PayerPolicy · EVICORE-RADIATION_ONCOLOGY-172B85F6A931

Summary of the payer’s published policy. Not a coverage determination — confirm with EviCore by Evernorth before submitting.

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Codes in this policy

Each code’s status is what the policy records for it. This page does not show the policy’s criteria. Read them in the payer’s source.

Codes this policy lists and each code’s status in the policy
Code	Code system	Status in this policy
77307	CPT	Covered
77321	CPT	Covered