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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.

Coverage

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 without distant metastases
  3. Pituitary neoplasms
  4. Other central nervous system tumors located near vital structures

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

Definitions

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.

Codes

Description

77520

Proton treatment delivery; simple without compensation

77522

Proton treatment delivery, simple with compensation

77523

Proton treatment delivery; intermediate

77525

Proton treatment delivery; complex

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

References

  1. Allen, A. M., Pawlicki, T., Dong, L., Fourkal, E., Buyyounouski, M., Cengel, K., … Konski, A. A. (2012). An evidence based review of proton beam therapy: The report of ASTRO’s emerging technology committee. Radiotherapy and Oncology, 103(1), 8–11.
  2. Abdalla, EK & Stuart, KE. Overview of treatment approaches for hepatocellular carcinoma. In: UpToDate, Tanabe, KK & Goldber, RM (Eds), UpToDate, Waltham, MA. (Accessed on October 27, 2016.)
  3. ASTRO (2013), Model Policy. Proton Beam Therapy (PBT).
  4. ECRI Institute, (2013). Health Technology Assessment. Proton Beam Therapy for Prostate Cancer. Plymouth Meeting, PA: ECRI Institute.
  5. Hayes Inc., Hayes Medical Technology Directory Report. Proton Beam Therapy for Ocular Tumors, Hemangiomas, and Macular Degeneration. Lansdale, PA: Hayes, Inc.; July 2004. Reviewed June 2009. Archived November 2011.
  6. Hayes Inc., Hayes Medical Technology Directory Report. Proton Beam Therapy for Thoracic and Abdominal Organs. Lansdale, PA: Hayes, Inc.; October 2006. Reviewed September 2010. Archived November 2011.
  7. Hayes, Inc. Hayes Medical Technology Directory Report. Proton beam therapy for prostate cancer. Lansdale, PA: Hayes, Inc.; June, 2016.
  8. Hickey, BE, Lehman, M, Francis, DP, See, AM. Partial breast irradiation for early breast cancer Cochrane Database of Systematic Reviews Issue 7. Art. No.: CD007077.DOI: 10.1002/14651858.CD007077.pub3.
  9. Laurie, SA. Malignant salivary gland tumors: treatment of recurrent and metastatic disease. In: UpToDate, Brockstein, BD, Posner, MR, Brizel, DM & Fried, MP (Eds), UpToDate, Waltham, MA. (Accessed on October, 2016.)
  10. Loeffler, JS & Shih, HA. Radiation therapy of pituitary adenomas. In: UpToDate, Snyder, PJ (Ed), UpToDate, Waltham, MA. (Accessed on October, 2016.)
  11. McDonald, M. W., Lawson, J., Garg, M. K., Quon, H., Ridge, J. A., Saba, N., … Beitler, J. J. (2011). ACR appropriateness Criteria® Retreatment of recurrent head and neck cancer after prior definitive radiation. International Journal of Radiation Oncology*Biology*Physics, 80(5), 1292–1298. 
  12. National Comprehensive Cancer Network. (2016a). NCCN Clinical Practice Guideline in Oncology Bladder Cancer. Version2.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  13. National Comprehensive Cancer Network. (2016a). NCCN Clinical Practice Guideline in Oncology Bone Cancer. Version1.2017-August 29, 2016. Fort Washington, PA: National Comprehensive Cancer Network.
  14. National Comprehensive Cancer Network. (2016b). NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. Fort Washington, PA: National Comprehensive Cancer Network.
  15. National Comprehensive Cancer Network. (2016c). NCCN Clinical Practice Guidelines in Oncology Central nervous systems cancers Version 1.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  16. National Comprehensive Cancer Network. (2016d). NCCN Clinical Practice Guideline in Oncology Cervical Cancer. Version1.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  17. National Comprehensive Cancer Network. (2016e). NCCN Clinical Practice Guideline in Oncology Colon Cancer. Version2.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  18. National Comprehensive Cancer Network. (2016f). NCCN Clinical Practice Guidelines in Oncology Esophageal and esophagogastric junction cancers Version 2.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  19. National Comprehensive Cancer Network. (2016g). NCCN Clinical Practice Guidelines in Oncology Gastric cancers Version 3.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  20. National Comprehensive Cancer Network. (2016h). NCCN Clinical Practice Guidelines in Oncology Head and neck cancers Version 2.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  21. National Comprehensive Cancer Network. (2016i). NCCN Clinical Practice Guidelines in Oncology Hepatobiliary Cancers version 2.2106. Fort Washington, PA: National Comprehensive Cancer Network.
  22. National Comprehensive Cancer Network. (2016j). NCCN Clinical Practice Guideline in Oncology Kidney Cancer. Version1.2017-September 26, 2016. Fort Washington, PA: National Comprehensive Cancer Network.
  23. National Comprehensive Cancer Network. (2016k). NCCN Clinical Practice Guidelines in Oncology Melanoma version 3.2106. Fort Washington, PA: National Comprehensive Cancer Network.
  24. National Comprehensive Cancer Network. (2016l). NCCN Clinical Practice Guidelines in Oncology Non-Small Cell Lung Cancer NCCN Evidence Block Version 4.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  25. National Comprehensive Cancer Network. (2016m). NCCN Clinical Practice Guidelines in Oncology Occult Primary version 2.2107. Fort Washington, PA: National Comprehensive Cancer Network.
  26. National Comprehensive Cancer Network. (2016n). NCCN Clinical Practice Guidelines in Oncology Ovarian cancer Version 1.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  27. National Comprehensive Cancer Network. (2016o). NCCN Clinical Practice Guideline in Oncology Pancreatic Adenocarcinoma. Version2.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  28. National Comprehensive Cancer Network. (2016p) NCCN Clinical Practice Guideline in Oncology Prostate Cancer; Version 3.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  29. National Comprehensive Cancer Network. (2016q). NCCN Clinical Practice Guidelines in Oncology Soft Tissue Sarcoma version 2.2106. Fort Washington, PA: National Comprehensive Cancer Network.
  30. National Comprehensive Cancer Network. (2016r). NCCN Clinical Practice Guideline in Oncology Uterine Neoplasms. Version2.2016. Fort Washington, PA: National Comprehensive Cancer Network.
  31. Park, JK, Vernick, DM & Ramakrishna, N. Vestibular schwannoma (acoustic neuroma). In: UpToDate, Loeffler, JS & Wen, PY (Eds), UpToDate, Waltham, MA. (Accessed on October 27, 2016.)
  32. Qi WX, Fu S, Zhang Q, Guo XM. Charged particle therapy versus photon therapy for patients with hepatocellular carcinoma: a systematic review and meta-analysis. Radiother Oncol. 2015 Mar;114(3):289-95.
  33. Snyderman C, Lin, D. Chordoma and chondrosarcoma of the skull base. In: UpToDate. Loeffler, JS, Wen, PY, & Fried, MP. (Eds), UpToDate, Waltham, MA. (Accessed on October 27, 2016).
  34. Washington State Health Care Authority, (2014). Health Technology Assessment. Proton Beam Therapy: Final Evidence Report.
  35. West, JH, VAllieres, E, Schild, SE. Management of state I and stage II non-small cell lung cancer. In: UpToDate, Jett, JR, Friedberg, JS, Lilenbaum, RC (Eds), UpToDate, Waltham, MA. (Accessed on October 3, 2016.)

Products

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
  • 03/01/2017 - Effective date
Review date
  • 12/2016
Revision date
  • 11/22/2016

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