Small changes can make a big difference when it comes to achieving timely reviews and faster case processing for your medical oncology requests. Check out these tips for an improved experience:
Submit the full medical oncology drug regimen for review
EviCore’s Medical Oncology team reviews treatment plans based on full drug regimens, in alignment with National Comprehensive Cancer Network (NCCN) guidelines.
Even if certain drugs (such as specific oral or IV therapies) are not reviewed under a particular health plan, it’s essential to include all medications in the online case questionnaire for accurate and timely case processing. Incomplete drug listings can lead to confusion and delays, as additional clarification may be required through letters or peer-to-peer consultations.
Bottom line: Submit the full drug regimen—even drugs not subject to review—to avoid delays.
Follow the prompts when filing for continuation of a medical oncology drug regimen
Oncology cases submitted on EviCore’s portal have prompts that enable timely review and case processing. The following will appear as prompts during case build/submission:
- “Additional Time” requests will pull forward all drugs and their prior dosing details from a previously approved treatment regimen.
- Whenever applicable, please enter any dosing changes from the last approved treatment regimen.
- If you need a new regimen or a continuation of only some treatments from the last approved regimen or need to add a treatment option, please select “Change in Treatment.”
Bottom line: Following the prompts will help with the accuracy of case submissions and lead to faster and more timely case processing.
Submit complete information to avoid unnecessary delays for Medicare requests
To comply with Centers for Medicare & Medicaid Services (CMS) regulations, standard Medicare oncology case requests must be fully processed within 72 hours, and urgent requests must be fully processed within 24 hours. To help ensure a timely and complete review, please include the following information with each submission:
1. Clinical notes:
- Most recent provider notes with history, including physical assessment and plan
- Prior and current treatments related to the patient’s condition
- Cancer type and stage (if applicable)
2. Test results:
- Relevant and recent lab work and imaging
- Pathology and molecular studies (if applicable)
3. Drug(s):
- All requested drug names with J-codes
If a case does not meet NCCN criteria and can’t be approved based on initial information, you’ll receive a request for additional details or an opportunity for a peer-to-peer consultation. This leaves a short time window to respond before the case must be finalized. If complete information isn’t received in that timeframe, the case will be unlikely to meet criteria for approval.
Bottom line: Submitting complete clinical notes, test results and drug details up front helps prevent delays and supports successful outcomes for your Medicare oncology case requests.
Appealing or submitting a retrospective request
All noncertified medical oncology requests have appeal rights that are most commonly filed directly with the health plan. Instructions on how to request an appeal, including process and time frame details, are provided in the letter sent to the provider’s office.
Bottom line: When submitting cases for an appeal or retrospective review, be sure to include relevant records that predate the actual date of service.