Proton Beam Radiation Therapy - FM HomeBuilders Consortium and Eide Bailly only

Policy ID: R-9006-02

Section: Radiation Therapy & Nuclear Medicine

Effective Date: January 01, 2019

Revised Date: April 01, 2022

Revision Effective Date: July 01, 2024

Last Reviewed: May 23, 2023

Applies To: Commercial Only

Description

Proton beam radiation therapy (PBRT) is a form of external radiation therapy in which positively charged subatomic particles, or protons, are targeted to a specific tissue mass through use of a stereotactic planning and delivery system. With this treatment, a focused dose of radiation is delivered to the target area while the surrounding healthy tissue receives minimal radiation.

The use of proton beam radiation may improve outcomes when the following conditions apply:

Conventional treatment modalities do not provide adequate local tumor control;
Evidence shows that local tumor response depends on the dose of radiation delivered; and
Delivery of adequate radiation doses to the tumor is limited by the proximity of vital radiosensitive tissues or structures

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

This criteria applies to covered members under FM HomeBuilders Consortium and Eide Bailly only,

I. Proton beam radiation therapy may be considered MEDICALLY NECESSARY AND APPROPRIATE in the following clinical situations:

Primary therapy for melanoma of the uveal tract (iris, choroid, or ciliary body), with no evidence of metastasis or extrascleral extension, and with tumors up to 24 mm in largest diameter and 14 mm in height; OR
Postoperative therapy (with or without conventional high-energy x-rays) in individuals who have undergone biopsy or partial resection of chordoma or low-grade (I or II) chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine and have residual localized tumor without evidence of metastasis; OR
Treatment of central nervous system (CNS) tumors in pediatric individuals (Less than 18 years of age). OR
Treatment of localized prostate cancer (i.e., organ-confined [T1 and T2] with no radiographic evidence of metastasis).

II. All other applications of proton beam radiation therapy are considered EXPERIMENTAL/INVESTIGATIVE due to a lack of evidence demonstrating an impact on improved health outcomes.

Other applications include, but are not limited to:

Non-small-cell lung cancer (NSCLC) at any stage or for recurrence;
Non-central nervous system tumors in pediatric individuals (Less than 18 years of age);
Tumors of the head and neck (other than skull-based chordomas or chondrosarcomas)

Procedure Codes

77520

77522

77523

77525

S8030

Coverage

Proton beam radiation therapy used in combination with intensity modulated radiation therapy (IMRT) in a single treatment plan is not covered.

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 3-17-2021 Annual Review-language update

Internal Medical Policy Committee 3-23-2022 Annual Review

Internal Medical Policy Committee 4-01-2022 Title Change - Effective 4-01-2022

Internal Medical Policy Committee 5-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 5-14-2024 Annual Review - no changes in criteria

Added Policy Application

Links

Not Applicable

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: R-9006-01

Section: Radiation Therapy & Nuclear Medicine

Effective Date: January 01, 2019

Revised Date: January 22, 2020

Last Reviewed: March 23, 2022

Archived Date: March 31, 2022

Applies To: Commercial Only

Description

The use of proton beam radiation may improve outcomes when the following conditions apply:

Conventional treatment modalities do not provide adequate local tumor control;
Evidence shows that local tumor response depends on the dose of radiation delivered; and
Delivery of adequate radiation doses to the tumor is limited by the proximity of vital radiosensitive tissues or structures

Criteria

This criteria applies to covered members under FM HomeBuilders Consortium only.

I. Proton beam radiation therapy may be considered MEDICALLY NECESSARY AND APPROPRIATE in the following clinical situations:

Primary therapy for melanoma of the uveal tract (iris, choroid, or ciliary body), with no evidence of metastasis or extrascleral extension, and with tumors up to 24 mm in largest diameter and 14 mm in height; OR
Postoperative therapy (with or without conventional high-energy x-rays) in individuals who have undergone biopsy or partial resection of chordoma or low-grade (I or II) chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine and have residual localized tumor without evidence of metastasis; OR
Treatment of central nervous system (CNS) tumors in pediatric individuals (< 18 years of age). OR
Treatment of localized prostate cancer (i.e., organ-confined [T1 and T2] with no radiographic evidence of metastasis).

II. All other applications of proton beam radiation therapy are considered EXPERIMENTAL/INVESTIGATIVE due to a lack of evidence demonstrating an impact on improved health outcomes.

Other applications include, but are not limited to:

Non-small-cell lung cancer (NSCLC) at any stage or for recurrence;
Non-central nervous system tumors in pediatric individuals (< 18 years of age);
Tumors of the head and neck (other than skull-based chordomas or chondrosarcomas)

Procedure Codes

77520

77522

77523

77525

S8030

Coverage

Proton beam radiation therapy used in combination with intensity modulated radiation therapy (IMRT) in a single treatment plan is not covered.

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 3-17-2021 Annual Review-language update

Internal Medical Policy Committee 3-23-2022 Annual Review, no changes in criteria

Links

Not Applicable

Disclaimer

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