1. (1) Evidence published in peer-reviewed medical journals listed on the Centers for Medicare and Medicaid Services (CMS) website.

2. (2) Evidence of acceptable survival rates with the proposed protocol in groups with similar clinical characteristics to the patient:

   1. (a) The current survival rate threshold is at least 75 percent one-year survival and at least 55 percent three-year survival; or
   2. (b) Similar characteristics include age, tumor type, tumor size, resection status, presence of metastases, etc.
3. (3) Study size with sufficient number of individuals for statistical analysis; or
4. (4) Evidence that the proposed protocol is a less costly alternative to other potential treatment protocols.

Requests for non-covered services are considered based on evidence submitted as to the efficacy of the requested services. These requests are reviewed on a case-by-case basis and require Medicaid Director or designee approval. Evidence types may include, but are not limited to:

KEY: Medicaid

Date of Last Change: June 19, 2025

Notice of Continuation: December 13, 2021

Authorizing, and Implemented or Interpreted Law: 26B-3-104