In July, the American Society for Radiation Oncology (ASTRO) updated its recommendations for medical insurance coverage for the use of proton beam therapy. Proton therapy offers a high degree of precision, which allows radiation oncologists to target an escalated dose of radiation directly on a tumor and spare nearby healthy tissue. New Bedford’s review of policy changes among large carriers, indicates that coverage is generally being extended to Hepatocellular cancer (no longer required to be treated in a hypofractionated regimen). Radiation oncology billing services and prior authorization services should be aware of the changes. One national carrier lists the following indications for medical necessity.
Proton beam radiation therapy is proven and medically necessary for definitive therapy of the following indications:
- Intracranial arteriovenous malformations (AVMs)
- Ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body and choroid)
- Skull-based tumors (e.g., chordomas, chondrosarcomas or paranasal sinus tumors)
- Localized, unresectable hepatocellular carcinoma (HCC) in the curative setting when documentation is provided that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy techniques, including intensity-modulated radiation therapy (IMRT), and stereotactic body radiation therapy (SBRT), and selective internal radiation spheres, and transarterial therapy (for example, chemoembolization) is contraindicated or not technically feasible.
The same carrier lists proton beam radiation therapy as unproven and not medically necessary for treating all other indications, including but not limited to:
- Age-related macular degeneration (AMD)
- Bladder cancer
- Brain and spinal cord tumors
- Breast cancer
- Choroidal hemangioma
- Esophageal cancer
- Gynecologic cancers
- Head and neck cancers
- Lung cancer
- Pancreatic cancer
- Prostate cancer
- Vestibular tumors (e.g., acoustic neuroma or vestibular schwannoma)
Proton beam radiation therapy may be covered for a diagnosis that is not listed above as proven, including recurrences or metastases in selected cases, when documentation is provided that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy techniques, including IMRT and stereotactic body radiation therapy (SBRT). Requests for exceptions are generally evaluated on a case-by-case basis so it is important for your radiation oncology billing service and prior authorization service to be updated on the latest coverage changes.