Modifiedevol entPolicy 7001

Evolent Clinical Guideline 7001 for Proton Beam Radiation Therapy and Neutron Beam Radiation Therapy Services

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This guideline governs medical-necessity indications and coverage conditions for proton beam radiation therapy (PBRT) and neutron beam radiation therapy (NBRT) services across Evolent lines of business, with additional statutory requirements for Oregon, Tennessee, and Washington.

Policy Summary

Payerevol ent

PolicyProton and Neutron Beam Radiation Therapy Services

Policy CodePolicy 7001

Change TypeModified

Effective DateJanuary 2026

Next Review DateN/A

Key ActionObtain prior authorization for applicable PBRT and NBRT services according to the member's plan requirements.

SourceLink

POLICY UPDATE CHANGES

Oropharynx cancer was removed from the listed indications.

The guideline added a clinical reasoning section and summary and analysis of evidence.

Tennessee legislation was added to the policy history.

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Modifiedevol entPolicy 7001

Evolent Clinical Guideline 7001 for Proton Beam Radiation Therapy and Neutron Beam Radiation Therapy Services

Customize your policy alerts

Sign up for evolent Policy 7001 alerts

Get alerted when Policy 7001 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payerevol ent

PolicyProton and Neutron Beam Radiation Therapy Services

Policy CodePolicy 7001

Change TypeModified

Effective DateJanuary 2026

Next Review DateN/A

Key ActionObtain prior authorization for applicable PBRT and NBRT services according to the member's plan requirements.

SourceLink

POLICY UPDATE CHANGES

Oropharynx cancer was removed from the listed indications.

The guideline added a clinical reasoning section and summary and analysis of evidence.

Tennessee legislation was added to the policy history.

10Adult PBRT cancer categories

≤18 yearsPediatric PBRT age

Any prior radiationRe-irradiation eligibility

1NBRT indication categories

3States with specific coverage language

47Listed procedure and billing codes

Medical Necessity and Coverage Criteria

Adult PBRT indications

PBRT is indicated for adults with any of the following cancer types or conditions:

Adult PBRT indications: Adult patient has liver hepatocellular carcinoma or intrahepatic bile duct cancer; paranasal sinus, nasopharyngeal, maxillary sinus, ethmoid sinus, or cavernous sinus cancer; spinal or skull-base chordoma or chondrosarcoma; benign or non-benign meningioma; arteriovenous malformation; acoustic neuroma; pituitary adenoma; intraocular (uveal) melanoma; or another brain or spinal tumor adjacent to the optic nerve, optic chiasm, brain stem, or spinal cord that cannot be sufficiently spared using IMRT or SRS.Adult cancer or condition listed in the guideline

For the other brain or spinal tumor category, the adjacent critical structure must be unable to be sufficiently spared with IMRT or SRS.

PBRT for re-irradiation

PBRT will be approved when all of the following are met:

PBRT re-irradiation: The patient has received any previous radiation to an anatomic location and now requires an additional course of radiation to that same anatomic area.Prior radiation to the same anatomic area

The treating physician determines the radiation dose and number of fractions based on the prior treatment history and, when possible, peer-reviewed literature. Radiation to a completely separate body area does not qualify as re-irradiation.

NBRT indication

NBRT is indicated when all of the following are met:

NBRT salivary gland cancer: The patient has salivary gland cancer that is unresectable or recurrent.Unresectable or recurrent

Oregon statutory coverage

For an Oregon health benefit plan that covers radiation therapy for prostate cancer, all of the following apply:

Oregon prostate cancer PBRT mandate: The health benefit plan provides coverage of radiation therapy for prostate cancer and the patient is receiving PBRT for prostate cancer.Coverage no less favorable than radiation therapy

PBRT must be covered on a basis no less favorable than radiation therapy. Prior authorization or other utilization review may be applied only if it is no more restrictive than the review applied to radiation therapy.

Tennessee statutory coverage

For Tennessee commercial coverage of a physician-prescribed hypofractionated proton therapy protocol, all statutory conditions must be satisfied:

Tennessee hypofractionated proton therapy: The patient is eligible and is being treated as part of a clinical trial or registry; the patient has a cancer type or indication that can be treated with a hypofractionated proton therapy protocol; the prescribing radiation oncologist is board certified or board eligible in radiation oncology; and the protocol is administered in a facility in Tennessee.All four statutory conditions

The state group insurance program pays the same aggregate amount as for the comparable standard radiation therapy treatment with IMRT for the same biological effective dose and indication.

NBRT for salivary gland cancer

NBRT is indicated when all of the following are met:

NBRT salivary gland cancer: The patient has salivary gland cancer that is unresectable or recurrent.Unresectable or recurrent

PBRT is not covered for conditions outside the covered or indicated circumstances described in this guideline. Coverage is limited to the specified clinical indications and applicable statutory requirements.

Procedure and Eligibility Coding

Codesmixed

32701
61796
61797
61798
61799
61800
63620
63621
77014
77261

1–10 of 47

1/5

Pediatric PBRT age

Age threshold18 years old or younger

Coverage statusPBRT is approved for all pediatric patients meeting the age criterion

TherapyProton Beam Radiation Therapy (PBRT)

Young-adult PBRT age

Age thresholdYounger than 21 years old

Qualifying histologyCancer with the same histology as a common pediatric cancer

TherapyProton Beam Radiation Therapy (PBRT)

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Obtain prior authorization before providing proton beam radiation therapy (PBRT) or neutron beam radiation therapy (NBRT). Authorization is subject to the guideline’s applicable service limitations and the member’s specific benefit coverage.

Documentation Required

Supporting Clinical Documentation

Submit all appropriate supporting clinical documentation with the request, including recent pertinent office visit notes, laboratory data, and results of any special testing. When applicable, include prior relevant imaging results and explain why alternative imaging cannot be performed.

Clinical and Guideline Background

This guideline addresses proton beam radiation therapy (PBRT) and neutron beam radiation therapy (NBRT), including their clinical indications and coverage conditions. PBRT is a precisely targeted radiation treatment intended to minimize exposure to surrounding healthy tissue; NBRT uses high-energy neutrons and is identified for unresectable or recurrent salivary gland cancers.

The guideline considers professional-organization guidance, including recommendations from the American Society for Radiation Oncology (ASTRO) and the National Comprehensive Cancer Network (NCCN). Coverage decisions also take into account treatment-related toxicity and the level of available medical evidence. Individual treatment decisions remain the responsibility of the treating physician.

Key Terms

Re-irradiation

DefinitionAdditional radiation treatment to an area of the body that has already received prior radiation to that same area

Prior treatmentThe anatomic location must have received radiation previously

Current treatmentAn additional course of radiation is required for the same anatomic area

Not re-irradiation

ExclusionRadiation to a completely separate body area is not considered re-irradiation

Example—prior treatmentRadiation treatment to the lung

Example—subsequent treatment

Policy Summary

Payerevol ent

PolicyProton and Neutron Beam Radiation Therapy Services

Policy CodePolicy 7001

Change TypeModified

Effective DateJanuary 2026

Next Review DateN/A

Key ActionObtain prior authorization for applicable PBRT and NBRT services according to the member's plan requirements.

SourceLink

On This Page

Billing Rule

Licensed Clinician Requirement

Ensure that care and services are provided by a licensed clinician. Treatment decisions remain the responsibility of the treating physician.

Documentation Required

Tumor Board and Treatment-Option Review

For adults age 21 and older requesting PBRT for a primary cancer outside the specifically listed categories, document that all other treatment options are contraindicated after review by a multidisciplinary tumor board. Include the tumor board review and treatment-option rationale in the authorization submission.

Listed primary cancers include esophageal, head/neck, skull-based, hepatocellular carcinoma, brain/spinal, and ocular cancers.

Documentation Required

Critical Structures Must Not Be Adequately Spared by IMRT or SRS

For other adult brain or spinal tumors, document that the tumor is adjacent to a critical structure and that the structure cannot be sufficiently spared using intensity-modulated radiation therapy (IMRT) or stereotactic radiosurgery (SRS).

Critical structures include the optic nerve, optic chiasm, brain stem, or spinal cord.

Documentation Required

NBRT Requires Unresectable or Recurrent Salivary Gland Cancer

For NBRT, the qualifying disease must be salivary gland cancer that is unresectable or recurrent. Include documentation supporting the disease status.

Unsupported block type: documentation

Denial Risk

Non-Covered Conditions

PBRT is not covered for all other conditions outside the covered primary cancers and applicable qualifying conditions. Requests that do not meet the listed coverage requirements may be denied.

For individuals age 21 and older, covered primary cancers include esophageal, head/neck, skull-based, hepatocellular carcinoma, brain/spinal, and ocular cancers, subject to conditions.
Other primary cancers require documentation that all other treatment options are contraindicated after multidisciplinary tumor board review.

Denial Risk

Unapproved Alternative Cancer Indication

For an adult primary cancer that is not specifically listed, document the alternative indication and the multidisciplinary tumor board’s determination that all other treatment options are contraindicated. Without this supporting review, the request may be treated as an unapproved alternative cancer indication.

Radiation treatment to the brain after lung radiation is not re-irradiation

Proton Beam Radiation Therapy (PBRT)

DefinitionRadiation treatment that precisely targets tumors while minimizing radiation exposure to surrounding healthy tissue

Clinical useIndicated for specific cancer types and for cancers near critical structures that cannot be sufficiently spared using IMRT or SRS

Additional indicationsApproved for pediatric patients, qualifying patients younger than 21, and re-irradiation cases

Neutron Beam Radiation Therapy (NBRT)

DefinitionRadiation treatment using high-energy neutrons

Covered cancer typeSalivary gland cancer

Required disease characteristicThe salivary gland cancer must be unresectable or recurrent

Re-irradiation

DefinitionAdditional radiation treatment delivered to an area that has already received prior radiation

Treatment areaThe additional radiation is delivered to the previously irradiated area

PBRT indicationPBRT is indicated when additional radiation is required for an area that has already received prior radiation