Proton Beam Therapy Form

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Proton Beam Therapy - Medical Policy
Updated Revision Effective: October 1, 2025 Policy Number:

UM408POL

Approval Date:

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Proton Beam Therapy (PBT) is a technology for delivering conformal external beam radiation with positively charged atomic particles to a well-defined treatment volume. PBT is approved by the U.S. Food and Drug Administration. Due to its unique dose deposition characteristics, PBT can, in certain situations, deliver the prescribed target dose to diseased tissue while giving a lower dose to normal tissues compared to photon-based forms of external beam radiotherapy.

Photon beams deposit their greatest amount of energy beneath the patient's surface with a gradual reduction in energy deposition along the beam path as photons pass through the target and then out through an exit point of the body. In contrast, the physical profile of a proton beam allows most of its energy to be deposited over a very narrow range of tissue at a depth largely determined by the energy of the proton beam. Compared to a photon beam, a proton beam deposits relatively less radiation energy upon entering the body. The energy deposition of the proton beam then rapidly increases over a narrow range of tissue at a desired depth to produce an intense dose distribution pattern called the Bragg peak. Beyond the Bragg peak, energy and dose deposition rapidly decrease, resulting in minimal exit dose deposited in normal tissue beyond the target.

 Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Refer to criteria under the Policy section in this medical policy. There are no MassHealth guidelines for Proton Beam Therapy.

Medicare:
Health New England follows Local Coverage Determination (LCD) L35075, Proton Beam Therapy. https://www.cms.gov/medicare-coverage-database/search.aspx

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Policy

I. Criteria for Commercial and Medicaid Lines of Business

A. Health New England has adopted InterQual criteria.

B. For members under 18 years of age, the request will be reviewed on a case-by-case basis.

C. Proton Beam Therapy for conditions that do not meet the above criteria are considered Experimental and Investigational.

II. Criteria for Medicare (LCD L35075, Proton Beam Therapy), follow below link.

https://www.cms.gov/medicare-coverage-database/search.aspx

Coding Guidance

Code
Description
77520 Proton beam treatment delivery, simple, without compensation PA Required 77522
Proton treatment delivery, simple, with compensation PA Required 77523
Proton treatment delivery, intermediate PA Required 77525
Proton treatment delivery, complex PA Required

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

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Date Update 9/11/2012 Initial Policy Date 08/2023 No changes 1/2024 Added Line of Business section 7/2024 Annual Review with no changes.
5/2025 Annual Review with no changes.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.