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Coverage criteria policies

Proton beam radiation therapy

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for proton beam radiation therapy.


Proton beam radiation therapy is generally covered subject to the indications listed below, and per your plan documents.

Indications that are covered

  1. Melanoma of the uveal tract that is not amenable to surgical excision or other conventional forms of treatment
  2. Chordomas or chondrosarcomas arising at the base of the skull or along the axial skeleton
  3. Pituitary neoplasms
  4. Other central nervous system tumors located near vital structures
  5. Hepatocellular cancer
  6. Malignancies in children age 21 and younger

Indications not covered

Proton beam radiation therapy is not medically necessary for the treatment of localized prostate cancer because it has not been proven to be more effective than other radiotherapy modalities for this indication.

Proton beam radiation therapy is considered experimental/investigational for all other conditions including, but not limited to:

  1. Lung cancer (including non-small-cell, small cell and other lung cancers)
  2. Bladder cancer
  3. Breast cancer
  4. Esophageal cancer
  5. Gynecological cancers (cervical, ovarian, uterine, vulvar)
  6. Age-related macular degeneration (AMD)
  7. Chorical hemangiomas
  8. Non-uveal melanoma
  9. Parotid gland tumor
  10. Colon cancer
  11. Kidney cancer
  12. Pancreatic cancer
  13. Rectal cancer
  14. Soft tissue sarcomas
  15. Salivary gland tumors
  16. Metastatic prostate cancer
  17. Head and neck cancers (other than skull-based tumors)
  18. Gastric cancer
  19. Anal cancer


Proton beam radiation therapy can be used alone or in combination with photon radiation therapy (the most common type of external beam radiation therapy), surgery, and chemotherapy to treat certain cancers and some noncancerous conditions. A proton beam's path is linear. Its depth of penetration is a function of its energy, and the point of energy release can be precisely determined.

Proton beams have less scatter than other sources of energy such as gamma rays, x-rays, or electrons. Because of this feature, proton beam radiotherapy (PBRT) has been used to escalate radiation dose to diseased tissues while minimizing damage to adjacent normal tissues. Proton beam radiotherapy has been shown to be particularly useful in treating radiosensitive tumors that are located next to vital structures, where complete surgical excision or administration of adequate doses of conventional radiation is difficult or impossible.

Proton beam radiation therapy can be delivered in a number of ways, including the traditional scattering method. This method is a recently developed technique of spot scanning with conformal beams and intensity- modulation. The more recently developed techniques were created with the intent of further decreasing potential damage to the surrounding normal tissue.

Proton beam radiation therapy is an outpatient procedure that is performed over the course of several days. The treatment regimen and duration vary depending on the type of cancer. Usually, treatment is given to a patient once daily, Monday through Friday, for up to eight weeks. The radiation doses are divided over this period to achieve the total dosage. After 2 initial planning sessions, each treatment session lasts between 20 to 40 minutes. Most of this time is spent aligning the patient for the prescribed treatment plan, while actual delivery of the proton beam only takes about one minute.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.




Proton treatment delivery; simple without compensation


Proton treatment delivery, simple with compensation


Proton treatment delivery; intermediate


Proton treatment delivery; complex

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.


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  2. Abdalla, EK & Stuart, KE. Overview of treatment approaches for hepatocellular carcinoma. In: UpToDate, Tanabe, KK & Goldber, RM (Eds), UpToDate, Waltham, MA. (Accessed on January 31, 2018.)
  3. American College of Radiology (ACR). ACR Appropriateness Criteria® Conservative Surgery and Radiation—Stage I And Ii Breast Cancer. 2015.
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  8. ASTRO (2017), Model Policy. Proton Beam Therapy (PBT).
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This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 09/02/2009 - Date of origin
  • 05/01/2018 - Effective date
Review date
  • 11/2018
Revision date
  • 04/20/2018

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