California Health & Wellness Policy for Proton and Neutron Beam Therapy

Date: 01/03/17

Proton Beam Therapy (PBT) is a form of External Beam Radiation Therapy (EBRT) that utilizes protons (positively charged subatomic particles) to precisely target a specific tissue mass. Proton beams can penetrate deep into tissues to reach tumors, while delivering less radiation to surrounding tissues. This may make PBT more effective for inoperable tumors, or for those areas in which damage to healthy tissue would pose an unacceptable risk. Neutron Beam Therapy (NBT) is a less widely available form of EBRT which utilizes neutrons. Its clinical use is very limited due to difficulties in the delivery of this treatment modality.

California Health & Wellness’ policy is that proton and neutron beam therapy is medically necessary for the following indications:

Ocular tumors with no distant metastasis; or
Primary or metastatic tumors of the spine where the spinal cord tolerance may be exceeded with conventional treatment or where the spinal cord has previously been irradiated; or
Tumors that approach or are located at the base of the skull, including but not limited to: chordoma or chondrosarcoma; or
Primary hepatocellular cancer treated in a hypofractionated regimen; or
Primary or benign solid tumors in members ≤ 18 years old; or
Members with genetic syndromes making total volume of radiation minimization crucial such as but not limited to NF-1 patients and retinoblastoma.
Treatment of salivary gland tumors considered surgically unresectable or for a patient who is medically inoperable.

All other indications for PBT and NBT are considered not medically necessary as insufficient evidence exists to recommend proton beam therapy as superior to other treatments available.

Note: policy is subject to change. For more information on this policy and other California Health & Wellness policies, please visit our website at www.CAHealthWellness.com.

CPT Codes for Proton Beam Therapy (PBT) considered medically necessary
for indications listed in this policy:

CPT Codes	Description
77520	Proton treatment; simple, without compensation
77522	Proton treatment delivery; simple, with compensation
77523	Proton treatment delivery; intermediate
77525	Proton treatment delivery; complex

ICD-10-CM codes that support coverage criteria for PBT
+ Indicates a code requiring an additional character:

ICD-10-CM Code	Description
C22.0	Liver cell carcinoma
C22.1 – C22.8	Malignant neoplasm of liver and intrahepatic ducts
C41.0	Malignant neoplasm of bones of skull and face
C41.2	Malignant neoplasm of vertebral column
C69.0 – C69.92	Malignant neoplasm of eye and adnexa
C70.0 – C70.9	Malignant neoplasm of meninges
C71.0 – C71.9	Malignant neoplasm of cerebrum, except lobes and ventricles
C72.0 – C72.9+	Malignant neoplasm of spinal cord
C75.1 – C75.3	Malignant neoplasm of pituitary, craniopharyngeal duct, and pineal gland
C79.31	Secondary malignant neoplasm of brain
C79.4 – C79.49+	Secondary malignant neoplasm of other and unspecified parts of nervous system
D32.0 – D32.9	Benign neoplasm of meninges
D33.0 – D33.9	Benign neoplasm of brain and other parts of central nervous system
D35.2	Benign neoplasm of pituitary gland
D44.3	Neoplasm of uncertain behavior of pituitary gland
D44.4	Neoplasm of uncertain behavior of craniopharyngeal duct

CPT Codes for Neutron Beam Therapy (NBT) considered medically necessary for indications listed in this policy:

CPT Codes	Description
77422	High energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking.
77423	High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)

ICD-10-CM codes considered medically necessary for NBT for adults:

ICD-10-CM Code	Description
C06.9	Malignant neoplasm of mouth, unspecified site (minor salivary gland, unspecified site)
C08.0 – C08.9	Malignant neoplasm of other and unspecified major salivary glands