Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Proton beam radiotherapy (PBRT) is a form of radiation treatment used to treat certain tumors that are located near vital organs.

2)    PBRT requires pre-authorization.

1)    Proton beam radiotherapy (PBRT) is considered  medically necessary in any of the following radiosensitive tumors:

a)    Uveal melanomas confined to the globe (i.e. not distant metastases) (HAYES B); or

b)    Chordomas or chondrosarcomas arising at the base of the skull or along the axial skeleton without distant metastases; or

c)     Pituitary neoplasms; or

d)    Other central nervous system tumors located near vital structures.

2)     Proton beam radiotherapy may be used either with or without stereotactic guidance. Stereotactic administration of proton beam radiotherapy is considered medically necessary only for the above-listed lesions that are located intracranially. Stereotactic administration of proton beam radiotherapy for extracranial lesions (i.e., stereotactic body radiosurgery) is not considered medically necessary.

3)    Proton beam radiotherapy is considered medically necessary in the treatment of intracranial arteriovenous malformations, with or without stereotactic guidance.

Codes Used In This BI:

77520 Proton treatment simple w/o comp
77522 Proton treatment simple w/comp
77523 Proton treatment intermediate
77525 Proton treatment complex
 

1)    Proton beam radiotherapy is considered experimental and investigational and is not covered for the following conditions;

A.    Age-related macular degeneration

B.    Non-uveal melanoma.

C.    Hepatocellular carcinoma

D.    Other forms of cancer such as; bladder, cervical, breast, esophageal and non-small cell lung

1)    Hayes, Medical Technology Directory; Proton Beam Therapy for ocular tumors, hemangiomas and macular degeneration, Jul 16, 2004

2)    Hayes, Medical Technology Directory; Proton Beam Therapy for Thoracic and Abdominal Organs; Oct. 24, 2006

3)    Hayes, Medical Technology Directory; Proton Beam Therapy for Prostate Cancer; Oct 28, 2006

4)    Arkansas BlueCross BlueShield, Coverage Policy Manual; Proton Beam Radiotherapy Treatment for Carcinoma of the Prostate. At: http://www.arkansasbluecross.com/members/report.aspx?policyNumber=1999006

5)    Arkansas BlueCross BlueShield, Coverage Policy Manual; Stereotactic Radiosurgery (Gamma Knife Surgery, Linear Accelerator, Proton Beam) at: http://www.arkansasbluecross.com/members/report.aspx?policyNumber=1997210

6)    Habrand JL, Schlienger P, Schwartz L, et al. Clinical applications of proton therapy. Experiences and ongoing studies. Radiat Environ Biophys. 1995; 34(1):41-44. 

7)    Tsuji H, Inada T, Maruhashi A, et al. Clinical results of fractionated proton therapy. Int J Radiat Oncol Bio Phys. 1993; 25(1):49-60. 

8)    Hug EB, Slater JD. Proton radiation therapy for Chordomas and chondrosarcomas of the skull base. Neurosurg Clin N Am. 2000; 11(4):627-638. 

9)    Munzenrider JE.  Uveal Melanomas. Conservation treatment.  Hematol Oncol Clin North Am.  2001; 15(2):389-402.

10) Noel G, Habrand JL, Jauffret E, et al.  Radiation therapy for Chordomas and chondrosarcoma of the skull base and the cervical spine. Prognostic factors and patterns of failure.  Strahlenther Onkol.  2003; 179(4):241-248.

11) Egger E, Zografos L, Schalenbourg A, et al.  Eye retention after proton beam radiotherapy for uveal melanoma.  Int J Radiat Oncol Biol Phys.  2003; 55(4):867-880.

12) Noel G, Habrand JL, Helfre S, et al.  Proton beam therapy in the management of central nervous system tumors in childhood: The preliminary experience of the Centre de Protontherapie d`Orsay.  Med Pediatr Oncol.  2003; 40(5):309-315.

13) Robertson DM.  Changing concepts in the management of choroidal melanoma.  Am J Ophthalmol. 2003; 136(1):161-170. 

14) Li W, Gragoudas ES, Egan KM.  Tumor basal area and metastatic death after proton beam irradiation for choroidal melanoma.  Arch Ophthalmol. 2003; 121(1):68-72. 

15) Ciulla TA, Danis RP, Klein SB, et al.  Proton therapy for exudative age-related macular degeneration: A randomized, sham-controlled clinical trial.  Am J Ophthalmol.  2002; 134(6):905-906.

16) Sivagnanavel V, Evans JR, Ockrim Z, Chong V. Radiotherapy for neovascular age-related macular degeneration. Cochrane Database Syst Rev. 2004 ;( 3):CD004004.

17) Zietman AL, DeSilvio ML, Slater JD, et al. Comparison of conventional-dose vs high-dose conformal radiation therapy in clinically localized adenocarcinoma of the prostate: A randomized controlled trial. JAMA. 2005; 294(10):1233-1239.

18) Kawashima M, Furuse J, Nishio T, et al. Phase II study of radiotherapy employing proton beam for hepatocellular carcinoma. J Clin Oncol. 2005; 23(9):1839-1846.

19) Al-Shahi R, Warlow CP. Interventions for treating brain arteriovenous malformations in adults. Cochrane Database Syst Rev. 2006 ;( 1):CD003436.