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 |
