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Proton Beam Radiation Therapy - FM HomeBuilders Consortium only

Effective Date: January 01, 2019
Last Reviewed: January 22, 2020

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 thefollowing conditions apply:

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

Criteria

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

  • 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 patients 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 patients (<18 years of age); or
    • Treatment of localized prostate cancer (i.e., organ-confined [T1 and T2] with no radiographic evidence of metastasis).
  • 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 patients (<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.