Point32 Commercial Clinical Policy

Point32 Proton Beam Therapy Form


Effective Date

08/01/2023

Last Reviewed

03/15/2023

Original Document

  Reference



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 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.

Point32Health companies 2263522Proton Beam Therapy

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

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