Independence is updating our policy on proton beam radiation therapy for
certain commercial members to reflect changes in coverage criteria. Medical
Policy #09.00.49j: Proton Beam Radiation Therapy was posted as a Notification
on July 3, 2018, and will go into effect October 1, 2018. Note:
This policy applies only to members of self-funded groups for whom eviCore?s
Radiation Therapy Services program are not applicable.
Changes to coverage criteria
Below is an outline of the changes to our coverage criteria.
Medically Necessary indications
Proton beam radiation therapy is considered medically necessary and,
therefore, covered for any of the following tumors:
- chordomas and chondrosarcomas of the base of the skull, localized and
in the postoperative setting
- uveal melanoma, when proton beam radiation therapy is considered
preferential compared to brachytherapy
- localized unresectable hepatocellular carcinoma (HCC)
- stage IIA seminoma
Not Medically Necessary
indications
Proton beam radiation therapy is considered not medically necessary and,
therefore, not covered for the treatment of the following tumors because
current evidence indicates that proton beam radiation therapy is no more
effective than other forms of radiation therapy (e.g., intensity-modulated
radiation therapy [IMRT]):
- previously untreated prostate cancer
- head and neck cancer (not including the brain)
- preoperative and definitive treatment of esophageal cancer
Experimental/Investigational
indications
Proton beam radiation therapy is considered experimental/investigational
and, therefore, not covered for all other indications, including the following,
because the safety and/or effectiveness of this service cannot be established
by review of the available published peer-reviewed literature:
- in the treatment of prostate cancer after prostatectomy
- when delivered in an ablative manner (i.e., stereotactic body radiation
therapy [SBRT])
- in combination with photon therapy for any tumor
For more information
To view the Notification for this policy, visit our Medical Policy Portal
and select Accept and Go to Medical Policy Online. Then select
Commercial under Active Notifications.