Point32 Proton Beam Therapy(Eff. beginning 1.1.24) Form

Proton Beam Therapy (PBT)

Proton Beam Therapy (PBT) uses a beam of protons that are targeted in a precise manner to irradiate specific diseased tissue while minimizing exposure to surrounding areas.

Clinical Guideline Coverage Criteria

The Plan uses guidance from the Centers for Medicare and Medicaid Services (CMS) and MassHealth for coverage determinations for its Dual Product Eligible plan members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals and MassHealth Medical Necessity Determinations are the basis for coverage determinations where available.

For Tufts Health One Care plan members the following criteria is used:

LCD - Proton Beam Therapy (L35075) (cms.gov)

The Plan considers proton beam therapy as medically necessary for the following indications:

• Melanoma of the uveal tract (iris, choroid, or ciliary body)
• Skull based tumors (e.g., chordomas and chondrosarcomas)
• Medulloblastoma
• Brain and spinal cord tumors
• Unresectable hepatocellular carcinoma (HCC)
• Intrahepatic cholangiocarcinoma
• Intracranial arteriovenous malformation (AVM) not amenable to surgical excision or other forms of treatment and/or adjacent to critical structures such as the optic nerve, brain stem or spinal cord.

Limitations

The Plan considers proton beam therapy coverage excluded as not the least intensive, most cost-effective service that can safely and effectively be applied for the following indications:

• Prostate cancer
• Vestibular schwannoma
• Lung cancer

The Plan considers proton beam therapy non-covered, investigational for the following indications:

• Age-related macular degeneration
• Bladder cancer
• Breast cancer
• Choroidal hemangioma
• Gastrointestinal cancers, including esophageal and pancreatic
• Gynecological cancers
• Head and neck cancers
• Lymphomas

Note: The Plan considers simultaneous use of proton beam therapy and intensity-modulated radiation therapy (IMRT) to be noncovered, investigational for any diagnosis

Codes