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| Medical Policy: |
R-18-011 |
| Topic: |
Proton Beam Radiation Therapy Treatment Delivery |
| Section: |
Radiation Therapy & Nuclear Medicine |
| Effective Date: |
January 6, 2014 |
| Issue Date: |
September 28, 2015 |
| Last Reviewed: |
June 2015 |
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Proton beam radiation therapy, also called particulate radiation is a treatment modality that delivers high dose radiation. This is different from conventional electron beam (photons) radiation therapy. Protons slow down faster and deposit more energy at precise depths. Majority of the radiation is delivered to the target site with minimal scatter, sparing surrounding or adjacent normal tissues. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Proton beam therapy is considered eligible when performed for the following indications:
- Chordomas and chondrosarcomas of the base of the skull or spine; or
- Melanoma of the uveal tract (iris, ciliary body, and choroid). There must be no evidence of extrascleral extension. The diameter of the tumor must not exceed 24 mm and the height must not exceed 14 mm; or
- Hepatocellular carcinoma; or
- Pediatric brain tumors such as posterior fossa tumors, optic pathway tumors, and brainstem lesions (from the report of ASTRO's emerging technology committee); or
- Pediatric CNS tumors; or
- Pediatric Spinal tumors
All other applications or uses of proton beam radiation therapy are considered experimental/investigational. Currently published medical literature does not provide sufficient documentation to permit conclusions concerning the effect on health outcomes. This modality remains an area of research. | Procedure Codes | | 77520, 77522, 77523, 77525 |
Place of Service: Outpatient
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Proton Beam Radiation Therapy Treatment Delivery is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
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