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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, including but not limited to use of proton beam therapy for non-small-cell lung cancer (NSCLC) at any stage or for recurrence, are considered investigational.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

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.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

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