Proton Beam Radiation Therapy
Defines medical necessity, proven indications, and coverage rationale for proton beam radiation therapy (PBT) for adults (19+) and notes automatic coverage for individuals under 19; identifies specific tumor sites and reirradiation criteria and describes when exceptions may be considered.
Primary Head and Neck Cancers are listed as a proven and medically necessary indication for definitive PBT when tumors are near critical structures and photon techniques cannot achieve adequate sparing.
Primary Central Nervous System Tumors are listed as a proven and medically necessary indication for definitive PBT when tumors are near critical structures and photon techniques cannot achieve adequate sparing.
Primary mediastinal tumors (for example thymomas, mediastinal lymphomas, thoracic sarcomas) were added to the proven/medically necessary list.
Reirradiation was added as a proven indication for PBT when prior radiation to the same site exists and photon techniques cannot spare normal tissue.
The prior specific HCC wording was replaced with a broader 'primary liver malignancies, such as hepatocellular carcinoma and intrahepatic cancer (localized, unresectable)' with the same requirement that photon techniques cannot achieve sparing.
Coverage criteria for exception requests were revised to remove the requirement that evaluation includes a comparison of treatment plans for PBT, IMRT, and stereotactic body radiation therapy.
Medical records documentation used for reviews was updated to add prior radiation history and need for additional course to the same site for re-irradiation.
Definitions were updated: new definitions for Base of Skull Tumors, Central Nervous System Tumors, Head and Neck Cancer, and an updated definition of 'Definitive Therapy'.
CPT/HCPCS codes 77385, 77386, G6015, G6016, and G6017 were removed from the Applicable Codes section.
Reference link to the Medical Policy titled 'Intensity-Modulated Radiation Therapy Coverage Rationale' was removed from Related Policies.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.