Some of oncology's most-fought authorizations turn on precise, documentable criteria, not clinical judgment alone. Check tumor genomic profiling, a hereditary-cancer panel, or proton beam therapy against your plan's real rules below.
Molecular and genetic testing runs through lab-benefit managers — eviCore and Carelon (Genetic / Hereditary Cancer Testing guidelines), plus Medicare's MolDX program — while proton therapy runs through radiation-oncology review (eviCore Radiation Oncology, Carelon Proton Beam Therapy). The gates are specific:
PET staging — another heavily-authorized oncology scan — is covered in our advanced imaging checker.
Answer a few plain questions about the stage, the criterion, or the indication, and see exactly what to document before the request is filed — about two minutes, free.
Check my coverageGenerally for advanced or metastatic cancer (recurrent, refractory, or stage III–IV) when a treatment decision is being made and the result will guide the choice of therapy, and when the same tumor hasn't already been comprehensively profiled. It's most defensible when the cancer type has a genomic biomarker linked to an FDA-approved therapy, and when a guideline-concordant NGS panel is used.
Almost always because a qualifying NCCN criterion wasn't documented. Germline panel testing is covered for things like a personal breast cancer diagnosed at 65 or younger, certain other personal cancers, a qualifying family history (such as a close relative with ovarian cancer or a known familial pathogenic variant), or a mismatch-repair-deficient tumor. Documenting the specific trigger — and, where required, genetic counseling — is what gets it approved.
Because for common adult cancers — prostate, breast, lung, GI — payers consider proton beam not medically necessary, since IMRT is the proven-equivalent standard. Proton therapy is covered for a defined set of indications (pediatric cancers, ocular melanoma, skull-base or spine chordoma/chondrosarcoma, CNS tumors near critical structures, and re-irradiation). For other sites, the recognized path to approval is a dosimetric comparison showing an IMRT plan can't safely meet the dose limits to nearby organs.
Yes, with specifics. Advanced-cancer NGS is covered under CMS's NGS national determination and the MolDX program; hereditary testing follows medical-necessity and MolDX rules; and proton therapy is covered per medical necessity with details in local coverage determinations. The criteria track the commercial standard closely.
Related: PET & advanced imaging coverage · Drug Lookup · Why prior authorizations get denied · all coverage tools