UnitedHealthcare Proton Beam Coverage Update

Coverage Criteria for Proton Beam Radiation Therapy (Louisiana Medicaid)

Individuals Younger Than 19 Years of Age

Covered without further review when ANY of the following conditions apply:

Pediatric coverage: Proton beam radiation therapy (PBRT/PBT) is covered without further review for individuals younger than 19 years of age.age < 19

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Individuals Age 19-20

For individuals age 19 and 20, PBT is proven and medically necessary for certain definitive therapy indications and may be considered for exceptions when ALL criteria are met:

Proven indications (age 19-20): PBT is proven and medically necessary as definitive therapy for: base of skull tumors (e.g., chordomas, chondrosarcomas, paranasal sinus, or nasopharyngeal tumors); hepatocellular carcinoma (localized, unresectable) in the curative setting when sparing cannot be achieved with standard techniques and alternative liver-directed therapies are contraindicated or not feasible; intracranial arteriovenous malformations (AVMs); and ocular tumors including intraocular/uveal melanoma (iris, ciliary body, choroid). PBT and IMRT are considered clinically equivalent for treating prostate cancer; medical necessity will follow the member's benefit terms.age 19-20

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Exceptions for other diagnoses (age 19-20): Requests for PBT for diagnoses not listed as proven may be covered on a case-by-case basis when BOTH: (1) documentation shows sparing of surrounding normal tissue cannot be achieved with standard radiation techniques (eg, IMRT, SBRT, selective internal radiation spheres, transarterial therapy), and (2) the evaluation includes a comparison of treatment plans for PBT, IMRT, and SBRT for the specific individual.N/A

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Individuals Age 21 and Older

Not covered:

Adults 21 and older: The Louisiana Medicaid Program does not cover proton beam radiation therapy (PBRT/PBT) for beneficiaries 21 years of age and older.age >= 21

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General coverage conditions and disease-site guidance

Covered when PBT is chosen because photon-based RT cannot meet normal tissue constraints or would compromise standard dosing, and when disease-site specific guideline recommendations support use:

General condition: PBT is considered when sparing of surrounding normal tissue cannot be adequately achieved with photon-based RT and PBT provides added clinical benefit to the individual (per ASTRO model policy).

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Disease-site guidance: Includes tumors where normal tissue constraints cannot be met with photons (for example: skull base tumors such as chordoma and chondrosarcoma), ocular tumors (intraocular/uveal melanoma), select head and neck primaries where photon therapy would compromise standard dosing, and other sites identified in guideline statements where PBT is an accepted option.

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Operational qualifiers: When PBT is requested to reduce dose to critical organs at risk (OARs) or to preserve function, prior authorization should include clinical documentation comparing photon and proton treatment plans and justification that acceptable OAR sparing cannot be achieved with IMRT/SBRT; consider trial enrollment when recommended by guidelines.

Liver tumors (HCC, ICC) coverage rationale

Covered when evidence supports clinical benefit or acceptable safety for specific liver tumors:

HCC and ICC evidence: Systematic reviews, multicenter registries, single-arm cohorts, and a randomized trial report favorable local control and acceptable hepatic toxicity for PBT in liver-confined hepatocellular carcinoma (HCC) and for intrahepatic cholangiocarcinoma (ICC); hypofractionated and dose-escalated regimens have shown high local control and low severe hepatic toxicity.

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Dose-response in liver PBT: Observational data demonstrate higher biological effective dose (BED) — e.g., BED > 75.2 GyE — or higher total dose correlates with improved local control in hypofractionated liver PBT cohorts.BED > 75.2 GyE

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Comparative evidence and practice guidance: A small randomized trial comparing PBT to TACE showed similar overall survival but trends toward improved local control and PFS with PBT; ASTRO and NCCN guidance support hypofractionation or proton use at experienced centers when selected based on tumor location and liver function.

Intracranial AVMs (coverage considerations)

Not routinely covered / coverage limited for unruptured intracranial AVMs when conservative management preferred:

AVM — conservative management evidence: The ARUBA randomized trial reported increased death or dependency with interventional treatment (including endovascular, surgical, and/or radiation) versus conservative management for unruptured brain AVMs during the one-year follow-up period; this finding may limit routine coverage of interventional radiotherapy for unruptured AVMs without clear indications.

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AVM — selected PBT/PSRS use: Retrospective and single-institution series report reasonable obliteration rates with proton stereotactic radiosurgery (PSRS) or multi-fraction approaches for selected AVMs, but patient selection, nidus size/location, and post-treatment hemorrhage risk influence appropriateness; coverage may be considered in selected high-risk cases or when other modalities are unsuitable.

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Ocular tumors

Covered for ocular tumors when performed at experienced centers:

Ocular melanoma: Particle/proton beam therapy for intraocular/uveal melanoma demonstrates high local control (five‑year LC >90%) with five‑year enucleation rates commonly around 5–10%; coverage is appropriate when delivered with volumetric planning and multidisciplinary ophthalmic oncology oversight at experienced centers.

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Prostate cancer

Prostate cancer — coverage stance and evidence summary:

Localized prostate cancer: PBT is relatively safe with favorable five‑year freedom‑from‑progression in several series, but high‑quality comparative evidence demonstrating superiority over photon EBRT or brachytherapy is lacking; medical necessity determinations should follow member benefit terms and may require documentation of clinical rationale and alternatives considered.

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Toxicity and outcomes: Multi‑institutional analyses report low rates of late grade ≥3 GU/GI toxicity with both moderately hypofractionated PBT and IMRT, and population studies show mixed comparative outcomes; ongoing randomized trials aim to clarify comparative effectiveness.

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Prostate cancer — evidence and guideline stance

Evidence and guideline context for PBT in localized prostate cancer

Prostate cancer evidence summary: Multiple observational and single‑institution prospective studies report favorable 5‑year freedom‑from‑progression and low rates of severe GU/GI toxicity with PBT, but comparative effectiveness versus IMRT/EBRT or brachytherapy is inconsistent and randomized data are limited. Guidelines (AUA/ASTRO, NCCN) acknowledge PBT as an option but do not establish superiority over photon therapies.

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Bladder cancer — evidence summary

Bladder cancer PBT evidence

Bladder cancer evidence summary: Available data are primarily small registry analyses and single‑institution series reporting encouraging short‑term overall survival, PFS, and local control with low rates of severe GI/GU adverse events, but sample sizes and follow‑up are limited. NCCN does not address PBT for bladder cancer.

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Brain/spinal cord tumors — evidence summary

Adult-type diffuse gliomas and glioblastoma evidence

Brain tumors evidence summary: Systematic reviews and imaging studies indicate PBT provides survival outcomes comparable to conventional RT for adult diffuse gliomas and may reduce radiation exposure to healthy brain tissue and related imaging changes; most data are retrospective and randomized trials with longer follow‑up are needed. ASTRO conditionally recommends PBT to reduce toxicity for IDH‑mutant grade 2–3 gliomas.

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AMD — evidence summary

Age-related macular degeneration (AMD) evidence

AMD evidence summary: Systematic reviews and randomized trials do not demonstrate consistent benefit of radiation therapy (including proton therapy) for neovascular AMD; AAO guidance states RT is not recommended for AMD.

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Conditional coverage by anatomic site

Coverage is conditional and generally supported when PBT is requested to reduce dose to critical OARs or to preserve function, particularly when photon techniques cannot achieve comparable sparing; guideline and evidence considerations by site include:

Brain and spinal cord tumors: PBT may be considered for adult diffuse gliomas and other brain/spine tumors to reduce dose to uninvolved brain and potentially preserve neurocognitive function; evidence shows comparable survival to photons with reduced exposure to healthy tissue but is limited by retrospective data; ASTRO conditionally recommends PBT when toxicity reduction is a priority.

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Breast cancer: PBT may be considered to spare heart, lungs, and contralateral breast when anatomy or reconstruction results in unacceptable photon dose; evidence is limited and of low quality though dosimetric advantages are reported.

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Esophageal cancer: PBT may be considered to reduce doses to thoracic OARs and potentially decrease pulmonary/pericardial toxicities and lymphocytopenia compared to photons; NCCN recommends PBT when OAR dose reduction is necessary and suggests trial enrollment when possible.

Site-specific evidence summary and conditional appropriateness

Summary of clinical stance by disease site and guideline context

Esophageal cancer: Prospective and retrospective data suggest PBT achieves favorable response rates and may improve dosimetry and some clinical outcomes; NCCN states PBT is appropriate when dose reduction to OARs is necessary and recommends clinical‑trial consideration (ongoing phase III NCT03801876).

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Rectal and other non‑metastatic GI cancers: Systematic reviews show dosimetric advantages of PBT (reduced pelvic, bowel, bladder dose) but insufficient evidence to demonstrate improved clinical outcomes; further RCTs are needed.

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Gynecologic cancers: Evidence is limited and mostly uncontrolled; NCCN does not address routine PBT for gynecologic malignancies and use should be limited to trials or selected cases.

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Coverage-relevant guideline and evidence statements

Excerpted coverage-relevant guidance derived from professional society statements and evidence summaries:

NSCLC and thoracic malignancies: ACR notes PBT may spare critical normal tissues but calls for more prospective studies; NCCN states PBT may be appropriate as an advanced technology when needed to safely deliver curative RT for NSCLC.

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Lymphomas: Small, lower‑quality studies report encouraging early outcomes for PBT in lymphomas focused on long‑term toxicity reduction; NCCN states PBT may be appropriate depending on clinical circumstances.

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Pancreatic cancer: Current evidence is limited and inconclusive; PBT remains investigational for pancreatic adenocarcinoma and NCCN does not address PBT for this indication.

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Retirement and 09/01/2025 Criteria Revision

Summary of notable coverage-related actions in this document part

Policy status and criteria revisions: Policy retired effective 04/01/2026; the 09/01/2025 revision updated coverage criteria for individuals age 19 and 20 to require that evaluations include a comparison of treatment plans for PBT, IMRT, and SBRT for the specific individual and removed a prior list of example unproven indications.

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Proton beam radiation therapy (PBT) is not covered for beneficiaries 21 years of age and older under the Louisiana Medicaid Program; claims for this age group will be denied per state policy.

The ARUBA randomized trial (A Randomized trial of Unruptured Brain Arteriovenous Malformations) found that interventional treatment—including endovascular, surgical, and/or radiotherapeutic interventions—was associated with an increased risk of death or dependency compared with conservative management at one year. These results inform a restrictive stance toward routine interventional radiotherapy for unruptured AVMs and support careful patient selection when considering radiosurgery or other invasive treatments.

The American Academy of Ophthalmology preferred practice patterns state that radiation therapy lacks sufficient data to demonstrate clinical efficacy and is not recommended for the treatment of age-related macular degeneration (AMD).

The evidence base for PBT across many adult indications is limited: most clinical reports are retrospective single‑institution series or small prospective cohorts, and randomized controlled trials are few. Requests that do not include a clear anatomic or clinical rationale demonstrating that PBT provides clinically meaningful organ-at-risk (OAR) sparing over feasible photon alternatives should be carefully scrutinized and may be denied.

NCCN guideline reviews do not address the use of proton beam therapy for certain sites, specifically gastric cancers and gynecologic malignancies (cervical, ovarian, uterine, vulvar), indicating a lack of guideline support for routine PBT in these disease sites.

There is no clinical evidence supporting the combined use of proton beam therapy and IMRT within a single treatment plan; combined PBT+IMRT plans lack supporting data and may be considered unsupported.

A previously included illustrative list of example unproven and not medically necessary indications for PBT was removed from the policy text during the 09/01/2025 revisions; operational edits clarified evidence and documentation expectations.

Outside of the specific proven indications listed for individuals age 19 and 20, PBT is considered unproven and not medically necessary due to insufficient evidence of efficacy; exceptions for other diagnoses may be considered only when documentation demonstrates that standard photon techniques cannot achieve the necessary normal‑tissue sparing and when a comparison of PBT, IMRT, and SBRT treatment plans for the individual is provided.

Given ARUBA's findings of increased death or dependence with interventional treatment of unruptured AVMs versus conservative management, routine interventional radiotherapy for unruptured intracranial AVMs may be considered not medically necessary unless strong patient‑specific indications exist.

Comparative data across many indications are inconclusive and often of low quality; therefore PBT should not be presumed medically necessary over photon radiotherapy or brachytherapy without clear comparative evidence or individualized justification showing meaningful clinical benefit.

Routine use of PBT is not supported when contemporary photon techniques (such as IMRT or conformal 3D‑CRT) can achieve comparable organ‑at‑risk sparing; approval generally requires demonstration that photon approaches cannot meet normal tissue constraints for the specific patient.

For many anatomic sites — including select gastrointestinal tumors (e.g., non‑metastatic rectal cancer), several head and neck subsites not listed as proven, and lung cancer — the current evidence is mixed or insufficient. Dosimetric advantages are reported in some studies, but clinical outcome benefits have not been consistently demonstrated, so routine PBT use for these indications remains unsupported outside clinical trials or clear individual justification.

Use of PBT for pancreatic adenocarcinoma is not supported by robust clinical evidence and is not addressed in NCCN guidelines, underscoring that PBT for pancreatic cancer remains investigational pending stronger prospective data.

Editorial updates removed specific example lists of unproven indications from the policy text; for remaining not‑medically‑necessary determinations and operational details, refer to other policy sections and plan‑specific benefit terms.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required (Ages 19–20)

Prior authorization is required for proton beam radiation therapy (PBT) requests for individuals age 19 and 20. Exceptions for diagnoses not listed as proven will be reviewed on a case-by-case basis and must include documentation that normal tissue sparing cannot be achieved with standard photon-based techniques. Prior authorization submissions must include a comparative evaluation of individualized treatment plans (PBT, IMRT, and SBRT) demonstrating that photon-based approaches cannot achieve the necessary organ-at-risk (OAR) sparing. Failure to provide the required comparative planning and clinical rationale may result in denial or delay of authorization.

Ages covered: 19–20
Required: Comparative treatment plans (PBT vs IMRT vs SBRT) for the specific individual
Exception review: Case-by-case when documentation shows unavoidable OAR dose reductions with PBT

Documentation Required

Advanced RT Technologies Justification

When requesting advanced radiation technologies such as PBT for thoracic tumors (including NSCLC), lymphoma, or other complex sites, the treating clinic must document the clinical circumstances that justify use of the advanced modality. Documentation should describe tumor location, motion-management and simulation methods (for example, 4D-CT or PET/CT when used), available technology (IMRT/VMAT, IGRT, motion management capabilities), and the institution's experience and physics support for delivering PBT safely. Requests for sites with significant motion or dose‑delivery complexity should demonstrate center expertise and quality assurance processes.

Applicable Procedure and Diagnosis Codes

Applicable CPT CodesCPT

77301	Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications.
77338	Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan.
77385	Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple.
77386	Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex.
77387	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed.
77520	Proton treatment delivery; simple, without compensation.
77522	Proton treatment delivery; simple, with compensation.
77523	Proton treatment delivery; intermediate.
77525	Proton treatment delivery; complex.

Applicable HCPCS/G-codesHCPCS

G6001	Ultrasonic guidance for placement of radiation therapy fields.
G6002	Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy.
G6015	Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session.
G6016	Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session.
G6017	Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment.

Applicable ICD-10 Codes (examples listed)ICD-10

C11.0	Malignant neoplasm of superior wall of nasopharynx.
C22.0	Liver cell carcinoma.
C30.0	Malignant neoplasm of nasal cavity.
C31.0	Malignant neoplasm of maxillary sinus.
C41.0	Malignant neoplasm of bones of skull and face.
C61	Malignant neoplasm of prostate.
C69.0	Malignant neoplasm of conjunctiva.
C69.3	Malignant neoplasm of choroid (and related codes).
D09.20	Carcinoma in situ of unspecified eye.
D14.0	Benign neoplasm of middle ear, nasal cavity and accessory sinuses.

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Referenced procedure codes (not specified in this excerpt)mixed

affected codes

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BED associated with improved local control in hypofractionated liver PBT — key threshold

BED threshold linked to improved LCBED > 75.2 GyE

Example PBT dose protocols (HCC GI protocol)

GI protocol — standard fractionation77.0 GyE in 35 fractions

GI protocol — intermediate fractionation72.6 GyE in 22 fractions

GI protocol — hypofractionated regimen66.0 GyE in 10 fractions

Definitions and Background Information

Proton beam therapy uses charged particles (protons) to deliver radiation with a more confined dose distribution than photons, producing minimal exit dose beyond the target. This dosimetric property can reduce exposure of normal tissues and potentially lower toxicity for selected tumors, but clinical benefit compared with photon techniques varies by indication and remains incompletely established for many adult cancers.

Definitive Therapy — definition

DefinitionRadiation treatments for cancer with a curative intent.

IntentCurative (definitive) intent rather than palliative or adjuvant settings.

Use contextApplied when treatment goal is eradication of known malignancy.

When PBT is reasonable — ASTRO rationale

ASTRO model-policy rationalePBT is considered reasonable when sparing surrounding tissue cannot be adequately achieved with photon-based RT and PBT provides added clinical benefit to the individual.

Evidence Summary and Rationale

The clinical evidence base is largely composed of retrospective series, single‑institution prospective trials, and systematic reviews; high‑quality randomized controlled trials are limited or absent for many tumor sites. This results in variable evidence quality and uncertainty about whether dosimetric advantages translate into better clinical outcomes across indications.

Site‑specific evidence details include ongoing randomized trials in esophageal and lung cancer and mixed results in thoracic disease: e.g., phase III and other prospective studies are in progress for esophageal cancer (NCT03801876) and NSCLC (NCT01993810), while existing trials and series report dosimetric benefits with inconsistent clinical outcome differences.

Guideline reviews and systematic analyses offer conditional recommendations for select sites. For example, systematic reviews of adult diffuse gliomas found comparable survival to photon RT with reduced normal‑tissue exposure, and vestibular schwannoma meta‑analysis reported high tumor control but limited hearing‑preservation benefit versus radiosurgery approaches; guidelines therefore emphasize selective use and further research.

Policy Updates and Revision History

2026-04-01retirementLatest

Policy retired and Louisiana plan membership disenrolled effective April 1, 2026; claims/requests after this date may be denied per plan administration.

2025-09-01criteria_revision

Revised coverage criteria for individuals age 19 and 20 to require that the evaluation include a comparison of treatment plans for PBT, IMRT, and SBRT for the specific individual and removed a previously listed set of example unproven/not medically necessary indications.

The policy was editorially updated to remove the prior list of example unproven indications and to refresh clinical evidence and references; these changes were documented in the 09/01/2025 revision notes.

OpenPayer

Proton Beam Radiation Therapy (for Louisiana Only)