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DESCRIPTIONCharged-particle beams consisting of protons or helium ions are a type of particulate radiation therapy. They contrast with conventional electromagnetic (i.e., photon) radiation therapy due to several unique properties including minimal scatter as particulate beams pass through tissue, and deposition of ionizing energy at precise depths (i.e., the Bragg peak). Thus, radiation exposure of surrounding normal tissues is minimized. The theoretical advantages of protons and other charged-particle beams may improve outcomes when the following conditions apply:
The use of proton or helium ion radiation therapy has been investigated in two (2) general categories of tumors/abnormalities:
1. Tumors located near vital structures, such as intracranial lesions or lesions along the axial skeleton, such that complete surgical excision or adequate doses of conventional radiation therapy are impossible. These tumors/lesions include uveal melanomas, chordomas, and chondrosarcomas at the base of the skull along the axial skeleton.
2. Tumors that are associated with a high rate of local recurrence despite maximal doses of conventional radiation therapy. The most common tumor in this group is locally advanced prostate cancer (i.e., Stages C or D1 [without distant metastases], also classified as T3 or T4).
Also see the related medical policy, Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT).
Charged-particle irradiation with proton or helium ion beams may be considered medically necessary in the following clinical situations:
Charged-particle irradiation with proton beams using standard treatment doses is considered not medically necessary in patients with clinically localized prostate cancer, because the clinical outcomes with this treatment have not been shown to be superior to other approaches including intensity modulated radiaton therapy (IMRT) or conformal radiation therapy yet proton beam therapy is generally more costly than these alternatives.
Other applications of charged-particle irradiation with proton beams are considered investigational. This includes, but is not limited to:
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY7/27/2006: Approved by Medical Policy Advisory Committee (MPAC)
9/28/2006: Policy updated to include coverage of prostate cancer
8/21/2008: Policy updated to note that coverage of prostate cancer is not medically necessary. ICD-9 diagnosis185 removed
04/27/2010: Added “Charged-Particle” to the policy title. Added link to related policy to the description. Made minor wording change in the policy statement: “may be considered” changed to “is considered” in the second statement. Intent of policy statement unchanged. Added the definition of investigative service to the Policy Guidelines section.
12/30/2010: Policy statement revised to add "including but not limited to use of proton beam therapy for non-small-cell lung cancer (NSCLC) at any stage or for recurrence" as a specific indication to the investigational policy statement. Intent of policy statement unchanged.
12/01/2011: Policy reviewed; no changes.
05/07/2013: Policy statement revised to state that charged-particle irradiation with proton or helium ion beams may be considered medically necessary in the treatment of pediatric central nervous system tumors. The following were added as investigational applications: pediatric non-central nervous system tumors and tumors of the head and neck (other than skull-based chordoma or chondrosarcoma).
SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.10
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.