At EviCore, the review process for chemotherapy and related supportive drugs is simple and:
- Clinically driven: EviCore uses National Comprehensive Cancer Network (NCCN) guidelines to review chemotherapy and supportive drug requests.
- Patient-oriented: All standard-of-care chemotherapy and supportive drug case requests are typically approved. See reasons for hold/non-certification below.
- Physician-led: Board-certified adult and pediatric medical oncologists review cases when immediate approval is not granted.
NCCN-supported standard of care requests will usually result in an approval if the correct and relevant clinical information is received for medical necessity review. On the web portal, if all the correct clinical data is entered, cases can often approve immediately upon submission.
Some of the reasons for non-certification of a requested regimen include:
1. Incomplete requests – Most initial requests not immediately approved are incomplete. A request is incomplete if it lacks recent relevant records and/or is an incompletely submitted case request. Examples include:
- Drugs not selected or missing dosing details
- Missing molecular tests
- Missing cancer stage indicator
2. Site of care conflict – Many health plans now have site of care requirements in their benefit design. If this applies to your request, the information will be presented when the pathway is completed. If a case is denied due to the site of care, then the options for additional review by the health plan will be outlined in the denial letter sent to the office.
3. Health plan formulary/preferencing – Many health plans have preferred biosimilar agents, which are presented if a non-preferred agent is selected. Choosing the health plan’s preferred agent will help expedite requests. If a non-preferred drug is selected after the health plan’s preferred, or “on-formulary”, agent is presented, the request may not be approved.
4. Clinical trials – Clinical trials will not be eligible for immediate approval if any of three key pieces of information are missing:
- NCT clinical trial number
- Names of standard drugs
- Names of investigational drugs