Humana Proton Beam, Neutron Beam and Carbon Ion Radiation Therapy Form

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. (Refer to Coverage Limitations Section)

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. (Refer to Coverage Limitations Section)

For information regarding coverage determination/limitations not addressed in this medical coverage policy, please refer to the following: Service Corresponding Medical Coverage Policy Brachytherapy Transperineal biodegradable material (SpaceOAR (Sp )} Intensity Modulation Radiation Therapy Stereotactic Radiosurgery and Stereotactic

Proton Beam, Neutron Beam and Carbon Ion Radiation Therapy Effective Date: 06/22/2023 Revision Date: 06/22/2023 Review Date: 06/22/2023 Policy Number: HUM-0369-019 Page: 3 of 18Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled.

Coverage Determination

Humana members may be eligible under the Plan for PBRT for the following indications:

• Base of skull or spine chondrosarcoma or chordoma; OR
• Inoperable intracranial arteriovenous malformations (AVMs); OR
• Malignant tumors in children (17 years of age or younger); OR
• Malignant tumors of the paranasal sinuses and other accessory sinuses for the following indications:
  • PBRT is needed to spare the orbit, optic nerve, optic chiasm or brainstem; OR
  • Tumors involving the base of the skull; OR
• Ocular tumors with no evidence of metastases or extrascleral extension (outside the sclera) including intraocular melanoma of the uveal tract (including the iris, choroid or ciliary body)

Humana members may be eligible under the Plan for NBRT for inoperable, unresectable or recurrent malignant salivary gland tumors.

Coverage Limitations

Humana members may NOT be eligible under the Plan for PBRT for any indications other than those listed above including, but not limited to:

• Acromegaly; OR
• Breast cancer; OR
• Cushing syndrome; OR
• Esophageal cancer; OR
• Glioblastoma; OR
• Head and neck cancer (eg, tonsillar cancer); OR
• Hepatobiliary cancer; OR
• Hepatocellular carcinoma; OR
• Lung cancer (eg, non-small cell lung cancer); OR
• Lymphomas (eg, B-cell, T-cell, Hodgkin); OR
• Meningioma; OR
• Mesothelioma; OR
• Pancreatic cancer; OR
• Pituitary neoplasms; OR
• Prostate cancer; OR
• Rectal cancer; OR
• Soft tissue sarcoma; OR
• Thymic tumor; OR
• Vestibular schwannoma (acoustic neuroma)

This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for NBRT for any indications other than those listed above. This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for CIRT for any indications. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Image guidance or positioning software utilized during the delivery of PBRT and NBRT is considered integral to the primary procedure and not separately reimbursable.

Additional information about cancer or AVMs may be found from the following websites:

• American Association of Neurological Surgeons
• National Cancer Institute
• National Comprehensive Cancer Network
• National Library of Medicine

Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Medical Alternatives

Alternatives to PBRT, NBR and CIRT include, but may not be limited to, the following:

• Chemotherapy
• Endovascular embolization
• External beam radiation therapy (EBRT)
• Intensity modulated radiation therapy (IMRT) (please refer to Intensity Modulated Radiation Therapy Medical Coverage Policy)
• Stereotactic radiosurgery (please refer to Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Medical Coverage Policy)
• Surgical excision

Physician consultation is advised to make an informed decision based on an individual's health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.