Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals.

Jurisdiction

• Type: LCD
• Title: Proton Beam Therapy
• ID Number: 35075
• Medicare Administrative Contractors (MACs): J6 - National Government Services, Inc. (Part A/B MAC)
• Applicable States/Territories: IL, MN, WI

• Type: LCA
• Title: Billing and Coding: Proton Beam Therapy
• ID Number: AS56827
• Medicare Administrative Contractors (MACs): JK - National Government Services, Inc. (Part A/B MAC)
• Applicable States/Territories: CT, NY, ME, MA, NH, RI, VT

• Type: LCD
• Title: Proton Beam Therapy
• ID Number: 136658
• Medicare Administrative Contractors (MACs): J15-CGS
• Applicable States/Territories: KY, OH

• Type: LCA
• Title: Billing and Coding: Proton Beam Therapy
• ID Number: AS55315
• Medicare Administrative Contractors (MACs): Administrators, LLC (Part A/B MAC)

• Type: LCD
• Title: Proton Beam Radiotherapy
• ID Number: 133937
• Medicare Administrative Contractors (MACs): JN - First Coast Service Options, Inc. (Part A/B MAC)

• Type: LCA
• Title: Billing and Coding: Proton Beam Radiotherapy
• ID Number: AS7669
• Medicare Administrative Contractors (MACs): Inc. (Part A/B MAC)
• Applicable States/Territories: FL, PR, US VI

Description

Proton beam radiation therapy (PBRT) is a type of external beam radiation (EBR) that utilizes protons (positively charged particle beams) that are precisely targeted to the specific tissue being treated. As the protons pass through the tissues, its velocity decreases until it reaches the Bragg peak (designated stopping depth) at which most of the proton energy is deposited. Because PBRT focuses its energy on the tumor, there is less radiation exposure to surrounding healthy tissues or organs. This may make PBRT more effective for inoperable tumors or in an individual in which damage to healthy tissue would pose an unacceptable risk.

PBRT can be delivered by either active or passive spreading. Active spreading, also known as spot scanning or pencil-beam scanning, utilizes smaller beams on smaller fields with narrower beams. Passive spreading utilizes modifying devices (eg, compensators, collimators) which scatter the proton beams before it enters the body. PBRT may also be known as intensity-modulated proton therapy (IMPT), pencil-beam scanning, proton beam radiotherapy, proton therapy or spot scanning.

Neutron beam radiation therapy (NBRT) is a specialized type of EBR that uses high-energy neutrons (neutral charged subatomic particles). The neutrons are targeted toward tissue masses that are characterized by lower tumor oxygen levels and a slower cell cycle, since neutrons require less oxygen and are less dependent on the cell’s position in the cell division cycle. Neutrons produce approximately 20 to 100 times more energy than conventional photon radiation and may be more damaging to surrounding tissues. For that reason, the radiation is provided utilizing a sophisticated planning and delivery system.

Carbon ion radiotherapy (CIRT) is a form of particle beam radiation similar to PBRT. Carbon ions are heavier than protons, which can create a higher mass and charge. It is theorized that this will provide greater ionization when the carbon ions reach their target site. Currently, this technology is being studied but is not yet available in the United States.

Imaging guidance and/or positioning software provides real-time imaging of the target site during radiation therapy to allow for increased accuracy of the radiation beams and decreased exposure to surrounding tissues.

Image guidance includes, but may not be limited to, computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound.

Coverage Determination

Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.

Please refer to the above CMS guidance for proton beam, neutron beam and carbon ion radiation therapy.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria:

Proton Beam, Neutron Beam and Carbon Ion Radiation Therapy

The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy.

Coverage Limitations

US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage