ModifiedUnitedHealthcarePolicy CS105NJ.R

Proton Beam Radiation Therapy (for New Jersey Only)

This policy governs coverage and medical necessity criteria for proton beam radiation therapy (PBT/PBRT) for UnitedHealthcare members in New Jersey aged 19 and older (with pediatric coverage exception noted). It specifies proven indications, documentation requirements, and coding references for providers seeking coverage.

Policy Summary

PayerUnitedHealthcare

PolicyProton Beam Radiation Therapy (for New Jersey Only)

Policy CodePolicy CS105NJ.R

Change TypeMaterial expansions and clarifications to proven indicationscoding removals

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization with documentation including indication, supporting records, and a comparison of PBT and photon-based treatment plans when photon techniques cannot spare normal tissue.

SourceLink

POLICY UPDATE CHANGES

Primary Head and Neck Cancers added as a proven and medically necessary indication for definitive PBT when tumors are near critical anatomical structures and photon techniques cannot spare normal tissue.

Primary Central Nervous System Tumors added as a proven and medically necessary indication for definitive PBT when tumors are near critical anatomical structures and photon techniques cannot spare normal tissue.

Primary mediastinal tumors (e.g., thymomas, mediastinal lymphomas, thoracic sarcomas) added to proven and medically necessary indications.

Reirradiation added as a proven and medically necessary indication when prior radiation was to the same anatomical site and photon techniques cannot spare normal tissue.

Expanded hepatocellular carcinoma indication to 'primary liver malignancies, such as hepatocellular carcinoma and intrahepatic cancer' with same sparing/contraindication rationale.

Coverage exception request evaluation criterion revised: plan comparison requirement now requires comparison of PBT and photon-based radiation therapy rather than PBT, IMRT, and SBRT explicitly.

CPT/HCPCS codes 77385, 77386, G6015, G6016, and G6017 removed from applicable codes.

Added definitions for Base of Skull Tumors, Central Nervous System Tumors, and Head and Neck Cancer and updated the definition of 'Definitive Therapy'.

Medical records documentation language added to emphasize documentation may be required to assess clinical criteria and does not guarantee coverage.

Clinical Evidence and References sections updated to reflect current information; prior policy version CS105NJ.Q archived.

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NJ onlystate-limited

age >= 19age threshold

severalnew proven indications

5codes removed

5+ proven indicationsproven indications listed

276,880large prostate cohorts cited

Coverage and Medical Necessity Criteria

Intracranial AVMs — Evidence Summary and Criteria

Covered when ALL of the following are met:

ALL of the following

Diagnosis of an intracranial arteriovenous malformation (AVM) in an adult individual
Clinical justification that proton stereotactic radiosurgery (PSRS) or fractionated proton therapy is indicated based on lesion characteristics (for example, nidus volume, location in deep/critical structures) and patient factors
Documentation that alternate definitive interventions (surgical resection, endovascular embolization) are unsuitable or have been considered and deemed nonoptimal
When used for single-fraction PSRS or multifactored fractionated regimens, documentation of the planned prescription dose and fractionation with rationale given AVM size and location
For re-treatment or staged approaches, documentation of prior therapies and multidisciplinary assessment of hemorrhage risk and expected obliteration rates

Ocular Tumors — Evidence and Considerations

Covered when ALL of the following are met:

ALL of the following

Diagnosis of an ocular tumor for which particle beam therapy is an established definitive local therapy (for example, intraocular/uveal melanoma involving the iris, ciliary body, or choroid)
Treatment will be delivered by an experienced multidisciplinary team including an ophthalmic oncologist, radiation oncologist, and particle beam physicist
Documentation of expected oncologic benefit and reason photon-based definitive options (including plaque brachytherapy when applicable) are not appropriate or achievable
Informed consent discussion documented including expected local control, survival outcomes, and potential ocular adverse effects (eg, glaucoma, optic neuropathy, cataract, visual acuity decline)

Primary Liver Malignancies — Evidence and Guideline Context

Covered when ALL of the following are met:

ALL of the following

Diagnosis of a primary liver malignancy (eg, hepatocellular carcinoma or intrahepatic cholangiocarcinoma) that is localized and unresectable with curative intent
Documentation that sparing of surrounding normal liver and adjacent organs cannot be achieved with standard photon techniques (IMRT, SBRT) and that transarterial therapies (eg, TACE) are contraindicated or not technically feasible when relevant
Treatment planning performed at an experienced center with appropriate dose-escalation rationale (including BED considerations) and reporting of liver function (Child-Pugh) to support safe delivery
When comparative effectiveness data are relevant, multidisciplinary review has considered available RCT and comparative evidence showing improved local control/PFS with PBT in some settings though OS differences may be limited; PBT should be selected when dosimetric or clinical factors favor proton therapy

Primary Mediastinal Tumors — Evidence and Guideline Context

Covered when ALL of the following are met:

ALL of the following

Diagnosis of a primary mediastinal tumor (eg, thymoma/thymic carcinoma, mediastinal lymphoma, thoracic sarcoma) where reduction of dose to cardiac, pulmonary, or breast tissue is clinically important
Documentation that advanced photon techniques (IMRT/VMAT) cannot reasonably meet normal tissue constraints or that proton dosimetry provides a clinically meaningful reduction in dose to organs at risk (eg, heart substructures, breasts) with potential long-term benefit
Patient selection considerations documented per guideline recommendations (eg, young female patients, extensive mediastinal disease involving heart contours, heavily pretreated patients at high risk for toxicity)
Treatment planning demonstrates preserved target coverage and dosimetric advantage to critical structures compared with photon plans

Gastrointestinal Cancers — Dosimetry Favored; Clinical Benefit Unproven

Coverage stance: dosimetric advantages are well documented but clinical benefit remains unproven for many GI sites. PBT may be considered when ALL of the following are met:

ALL of the following

Diagnosis of a gastrointestinal malignancy for which PBT is being considered (examples include rectal cancer, pancreatic cancer, esophageal cancer)
Documentation that comparative dosimetry demonstrates a meaningful reduction in dose to organs at risk (eg, small bowel, bladder, pelvic bone marrow, heart, lungs) compared with advanced photon techniques
Evidence that clinical equipoise and current evidence do not conclusively show superior clinical outcomes (eg, OS, PFS) with PBT for this indication; institution commits to appropriate data collection and consideration for clinical trial enrollment when available
When PBT is requested for esophageal cancer, documentation should address necessity for OAR dose reduction and consideration for enrollment in clinical trials per NCCN guidance

Lung Cancer — Mixed Evidence; Dose-Dependent Benefits and Risks

Covered or may be considered when ALL of the following are met; note that evidence is mixed and outcomes may be dose dependent:

ALL of the following

Diagnosis of lung cancer (NSCLC or selected small cell lung cancer scenarios) for which curative-intent radiation is planned
Documentation that proton therapy provides dosimetric advantages or allows dose escalation that cannot be achieved safely with photon techniques, with explicit plan comparisons between PBT and IMRT/VMAT
Treatment intent, fractionation, and biologically effective dose (BED) are specified; when hypofractionated regimens are used, higher BED (eg, ≥ approximately 105.6 Gy [RBE] in some series) has been associated with improved local control and survival but also higher rates of late toxicity
Multidisciplinary assessment documents patient-specific risks (eg, tumor location, pulmonary function) and institutional experience with proton delivery techniques; when enrolling in nontrial settings, center should demonstrate mechanisms to monitor and mitigate dose-related risks such as rib fracture or late pneumonitis

Coverage Exceptions — Evaluation Requirements

Exceptions to standard coverage for indications not listed as proven will be evaluated on a case-by-case basis when ALL of the following are provided:

ALL of the following

Clinical documentation supporting the specific indication and rationale for proton therapy over photon-based approaches (including tumor site, size, proximity to organs at risk, prior treatments)
A direct, contemporaneous plan comparison for the individual showing the PBT plan and at least one photon-based plan (eg, IMRT or SBRT) with dosimetric comparisons and justification for how PBT improves normal tissue sparing or target coverage
Operational note: provide dose-volume histograms and mean/maximum doses for key OARs.
Documentation that sparing of surrounding normal tissue cannot be achieved with standard photon radiation therapy techniques
Multidisciplinary evaluation and, when applicable, consideration of clinical trial enrollment; when prior radiation exists, include prior dose details and overlap assessment

Procedure and Diagnosis Codes

Applicable Procedure/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.
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 Diagnosis/ICD-10 Codes (selected examples from list)ICD-10

C11.0	Malignant neoplasm of superior wall of nasopharynx.
C22.0	Liver cell carcinoma.
C61	Malignant neoplasm of prostate.
C69.31	Malignant neoplasm of right choroid.
Q28.2	Arteriovenous malformation of cerebral vessels.

Removed CPT/HCPCS CodesmixedNot Covered

77385	removed
77386	removed
G6015	removed
G6016	removed
G6017	removed

No explicit CPT/HCPCS/ICD codes in this document segmentmixed

No codes listed

No explicit codes in this excerptmixed

No codes listed

inv-46: AVM nidus volume — median 3.5 cc (evidence metric)

MetricMedian AVM nidus volume 3.5 cc (single-institution PSRS series)

Associated outcome64.6% obliteration at median follow-up 35 months

Time to obliterationMedian time to total obliteration 31 months

inv-47: Karnofsky Performance Status — KPS > 60 referenced

KPS threshold referenced> 60

Context of useEligibility criterion reported in prospective reirradiation study (performance status requirement)

Prior Authorization, Documentation, and Operational Requirements

Prior Authorization

Prior Authorization Recommended for Select and Evolving Indications

Prior authorization is recommended for select proton beam therapy (PBT) uses, including mediastinal lymphoma, thymic malignancies, reirradiation cases, and other situations where dose-sparing of organs at risk (OARs) is critical. Requests for PBT for indications with evolving or limited evidence should be submitted for prior authorization so reviewers can assess the clinical rationale and supporting documentation.

Recommended prior authorization for mediastinal lymphoma, thymic malignancies, reirradiation, and select other indications
Use prior authorization to document trial enrollment or rationale for nontrial use

Prior Authorization

Prior Authorization Advised for Unproven/Evolving Indications

Prior authorization is advised for unproven or evolving indications (for example, many adult solid tumors such as NSCLC, pancreatic cancer, or other limited-evidence sites). Reviewers will evaluate the available evidence, clinical details, and rationale; absence of robust evidence or failure to justify why PBT is necessary may result in denial.

Requests for unproven indications should include detailed clinical rationale and literature support when available

Clinical Background and Evidence Summary

Proton beam therapy uses charged protons to deliver a highly conformal radiation dose with minimal exit dose beyond the target. This physical property can provide organ‑sparing advantages compared with photon techniques, which is the primary rationale for selecting PBT when critical organs at risk cannot be adequately spared with standard photon radiation methods.

Definitions and Key Terms

inv-89: Base of Skull Tumors — definition (examples include chordomas, chondrosarcomas)

DefinitionDiverse group of lesions arising in the anatomically complex base of skull region including the anterior cranial fossa, clivus, petrous bone, middle cranial fossa, cavernous sinus, and infratemporal fossa

Common examplesChordomas and chondrosarcomas

Clinical relevanceTumors often located adjacent to critical endocrine, neurologic, and vascular structures requiring specialized planning

inv-90: Central Nervous System Tumors — definition (brain and spinal cord neoplasms)

DefinitionTumors that originate in the central nervous system, including brain and spinal cord neoplasms (examples: brainstem glioma, craniopharyngioma, medulloblastoma, meningioma)

Anatomic scope

Policy Updates and Revision History

2026-05-01RevisionLatest

Added primary head and neck cancers, primary central nervous system tumors, primary mediastinal tumors, reirradiation, and expanded primary liver malignancies to proven and medically necessary indications for definitive proton beam therapy; replaced narrower HCC wording with broader 'primary liver malignancies' language.

2026-05-01Code removal

Removed CPT/HCPCS codes 77385, 77386, G6015, G6016, and G6017 from the list of applicable codes.

2026-05-01Policy criteria revision

Policy Summary

PayerUnitedHealthcare

PolicyProton Beam Radiation Therapy (for New Jersey Only)

Policy CodePolicy CS105NJ.R

Change TypeMaterial expansions and clarifications to proven indicationscoding removals

Effective DateMay 1, 2026

Next Review DateN/A

SourceLink

On This Page

Identification of the treating facility's proton experience and quality-assurance processes to support complex planning and delivery

Documentation expectationPerformance status should be documented in medical record for reirradiation requests

Reviewers will assess evidence limitations and clinical eligibility for coverage

Documentation Required

Trial Eligibility or Rationale Required

When the requested PBT is for an indication with an active clinical trial, documentation must state whether the individual is enrolled in that trial. If not enrolled, provide a clear rationale explaining why trial participation is not appropriate or feasible for this individual.

State trial name and ClinicalTrials.gov ID if applicable
If not enrolled, provide justification for nontrial use

Documentation Required

Documentation Must Support Medical Necessity; Insufficiency May Lead to Denial

Medical records must fully support the medical necessity for requested services. Documentation insufficiency—such as missing history, exam findings, prior photon plan comparisons, prior radiation dose details for reirradiation, or illegible records—may delay review or result in denial.

Include relevant history, physical exam, and diagnostic test results
Incomplete or illegible records may trigger denial or request for additional information

Denial Risk

Potential Denial Trigger — Photon Techniques Adequate

Requests may be denied if photon-based therapy (including advanced techniques such as IMRT/VMAT or SBRT) can meet OAR constraints and achieve the treatment objectives. Prior authorization submissions should document why photon techniques are inadequate for the individual case.

Demonstrate that photon techniques cannot meet OAR constraints to justify PBT
Plan comparison required when PBT is requested for exceptions to listed proven indications

Note

Address Clinical Eligibility and Evidence Limitations

Clinical eligibility and evidence limitations must be addressed in the submission. For indications with limited or conflicting evidence, provide population-specific details, expected benefit, and alternative options considered. Coverage decisions will reflect the strength of evidence and individual clinical circumstances.

Address evidence gaps and expected outcomes for limited-evidence indications
Provide individualized clinical justification for PBT use

Documentation Required

Documentation Expectations for Reirradiation Cases

For reirradiation requests, include prior radiation dose distributions, total dose delivered, fractionation, elapsed interval since prior RT, anatomic overlap of fields, and the patient’s performance status. These details are required to assess feasibility and safety of PBT reirradiation.

Provide prior RT dose, fields, and isodose overlap information
Document interval since prior RT and performance status

Prior Authorization

Appropriateness Tied to Demonstrated Dosimetric Need

PBT is considered appropriate when dosimetric need is demonstrated — specifically when photon-based planning cannot meet OAR constraints or would compromise tumor dosing. Prior authorization should include comparative dosimetry showing the OAR-sparing advantage of PBT.

Include comparative dose-volume histograms (DVHs) for PBT and photon plans
Show which OAR constraints cannot be met with photon-based therapy

Note

Combined PBT + IMRT Unsupported in a Single Plan

There is no evidence supporting the routine combination of PBT and IMRT within a single treatment plan. Requests proposing combined-modality plans should note that combined PBT+IMRT in a single plan is unsupported by current literature.

Combined PBT+IMRT in a single plan is not supported by evidence

Note

No Explicit Authorization or Denial in This Segment; Check Governing Benefits

This section does not itself authorize or deny services. Coverage decisions are determined in accordance with applicable federal, state, and contractual benefit requirements and the medical review of submitted documentation. Verify governing benefit limits and requirements before submitting authorization requests.

Check federal, state, and contractual coverage rules that may supersede this policy
This section provides operational guidance and does not guarantee coverage

Documentation Required

Center Expertise and Multidisciplinary Justification

Center expertise and multidisciplinary justification strengthen requests for PBT in complex cases. When relevant, document the treating center’s experience, availability of particle-beam physicists, and multidisciplinary team involvement (radiation oncologist, surgeon, medical oncologist, specialty physicians).

Document center experience and relevant specialist participation
Include physics support and treatment planning expertise when applicable

Documentation Required

Supportive Clinical Documentation Recommended

Supportive clinical documentation is recommended for all PBT requests. Include tumor site, size, proximity to OARs, prior therapies, performance status, comorbidities, motion management strategies, and any prior photon planning attempts.

Tumor characteristics, prior treatments, and intent of therapy (curative vs palliative)
Motion management and prior photon plan summaries

Note

Revision History Note

This segment contains policy revision-history information elsewhere in the document. Refer to the Policy History / Revision Information section for details of prior updates.

See Policy History / Revision Information for archived versions and summaries

Note

Check Governing Benefit and Operational Requirements

Before applying this policy, check governing federal, state, and contractual benefit requirements. These requirements may mandate coverage or create exceptions not reflected in the standard policy. UnitedHealthcare uses third-party tools (for example, InterQual) as applicable in administering benefits.

Verify plan-specific requirements before submission
UnitedHealthcare may apply third-party clinical tools in benefit determinations

Prior Authorization

Plan Comparison Required for Exception Requests

Plan comparison is required for exceptions to the listed proven indications. When requesting PBT for a diagnosis not explicitly listed as proven, include a direct comparison of the proposed PBT plan with photon-based plans (IMRT/VMAT/SBRT) demonstrating unmet OAR constraints with photons.

Provide photon and proton plan DVHs and planning assumptions
Explain why advanced photon alternatives cannot meet constraints

Step Therapy

Step from Photon to Proton — Consider Advanced Photon Techniques First

Clinical practice requires stepping from photon to proton when advanced photon techniques (IMRT/VMAT/SBRT) cannot meet normal tissue constraints. Document that appropriate advanced photon techniques were considered and why they are insufficient before electing PBT.

Consider IMRT/VMAT/VMAT and motion management prior to PBT when appropriate
Document why photon techniques are unsuitable in the individual case

Note

Photon vs Proton Consideration — Use Guideline-Driven Decision Making

Photon versus proton decisions should follow guideline-driven considerations: prefer advanced photon therapy (IMRT/VMAT) when OAR constraints and tumor coverage can be met; reserve PBT for situations where photon techniques would compromise OARs or tumor dosing.

Follow ASTRO/NCCN guidance when choosing modality
Document guideline-concordant decision-making in the record

Note

Consider Standard Therapy Alternatives Prior to PBT

Consideration of standard (nonradiation) therapies and multidisciplinary alternatives should be documented where applicable. PBT should not replace standard nonradiation options when those are clinically indicated.

Document prior systemic or surgical options considered and reasons PBT is preferred

Documentation Required

Prior Photon Therapy Planning — Provide Comparative Plans

Prior photon therapy planning may be required for many PBT requests. When applicable, submit prior photon plans (IMRT/3D-CRT/SBRT) with DVHs to demonstrate that photon planning could not meet constraints or achieve required sparing.

Include prior photon plan files or summary DVHs when available

Step Therapy

Consider Advanced Photon Alternatives Before PBT

Consider advanced photon alternatives first for many disease sites (IMRT/VMAT/SBRT). If advanced photon techniques can meet OAR and tumor dose constraints, PBT may be considered not medically necessary.

Document attempts with advanced photon techniques before PBT authorization

Note

Operational Note — Some Prior Authorization Details Are Plan-Specific

Not all elements of prior authorization are specified in this section of the policy. Follow plan-specific prior authorization processes and include all requested operational forms, imaging, and planning data as required by the member's benefit plan.

Use the applicable plan's prior authorization portal and requirements
Supplemental plan-specific documentation may be required

Includes intracranial and intraspinal neoplasms

Policy relevanceListed as a proven indication for definitive PBT when tumors are near critical structures and photon techniques cannot spare normal tissue

inv-91: Medically Necessary Services — definition of medically necessary

DefinitionServices or supplies necessary to prevent, evaluate, diagnose, correct, prevent worsening of, alleviate, ameliorate, or cure a physical or mental illness or condition and consistent with standards of good medical practice

Evidence basisMust be based on peer-reviewed publications, expert opinion, and medical community acceptance

ExclusionsExperimental services or treatments generally regarded as unacceptable are not medically necessary

inv-92: Organ-at-risk (OAR) sparing — definition and examples

DefinitionDeliberate reduction of radiation dose to nearby normal tissues (organs at risk) using highly conformal techniques to minimize acute and long-term toxicity

Examples of OARsOptic apparatus, brainstem, pituitary, cochleae, salivary glands, heart, lungs, breast tissue

Clinical goalUsed to justify PBT when photon techniques cannot meet dose constraints to critical structures

inv-93: PBT — particle/proton beam therapy definition and clinical intent

DefinitionParticle/proton beam therapy (PBT): a charged-particle radiation modality used to deliver conformal dose with minimal exit dose, favored when sparing surrounding tissue cannot be adequately achieved with photon RT

Clinical intentIntended to reduce radiation exposure to adjacent organs-at-risk and potentially reduce long-term toxicity

Typical indicationsTumors near critical structures (ocular, skull base, CNS, mediastinal) or for reirradiation when photon techniques cannot spare normal tissue

inv-94: OAR (Organ at Risk) — definition and examples

DefinitionCritical normal structures whose radiation exposure is minimized during planning (organs at risk)

ExamplesHeart, lungs, breast tissue, optic apparatus, brainstem, pituitary, cochleae, salivary glands

Role in coverageDemonstrated OAR dose reduction compared with photon plans is a required justification for many PBT indications and exceptions

inv-95: Reirradiation — definition and individualized assessment needs

DefinitionDelivery of an additional course of radiation therapy to a previously irradiated anatomical site

Assessment needsRequires individualized assessment including prior radiation dose, extent/location of overlap, time interval since prior RT, and performance status

DocumentationMedical record must document prior RT details; failure to provide may lead to denial

inv-96: PBT / PBRT — definition alias for proton beam radiation therapy

Definition aliasPBT / PBRT — proton beam radiation therapy; charged-particle modality intended to spare surrounding organs at risk compared with photon-based external beam radiation

Terminology notePBRT used interchangeably with PBT and includes charged-particle approaches

Clinical contextReferenced across guidelines when photon techniques cannot meet OAR constraints

inv-97: AMD (neovascular age-related macular degeneration) — definition and contemporary standard therapy

DefinitionAMD (neovascular age-related macular degeneration): retinal condition with choroidal neovascularization leading to vision loss

Contemporary standard therapyIntravitreal anti-VEGF agents are the current standard of care; radiotherapy role is uncertain

Policy stanceRT/PBT for neovascular AMD considered uncertain/unproven pending further high-quality trials

inv-98: Hypofractionated PBT — definition (≥3 Gy RBE per fraction)

DefinitionHypofractionated PBT: proton therapy delivered in larger dose per fraction, defined here as ≥ 3 Gy (RBE) per fraction

Clinical noteUsed in some early-stage NSCLC studies with higher biologically effective doses and dose‑response relationships

Outcome implicationsHigher BED associated with improved local control but increased late toxicity in some series

inv-99: PSPT — passive scattering proton therapy definition

DefinitionPSPT — passive scattering proton therapy: a proton delivery technique historically used in randomized and nonrandomized studies

Comparative contextCompared with IMRT in trials (e.g., lung cancer), with different dose distributions and learning-curve effects

RelevanceTechnique referenced in evidence comparing PSPT vs IMRT outcomes and toxicities

inv-100: Charged particle therapy / PBRT — broader definition including protons and heavier ions

DefinitionCharged particle therapy / PBRT: radiation therapy delivered with protons or heavier charged particles (e.g., carbon ions) intended to reduce dose to normal tissues compared with photons

ScopeIncludes protons and heavier ions; clinical effectiveness varies by indication and particle type

Evidence noteHeavier ions (carbon) have distinct RBE and clinical profiles referenced in systematic reviews and trials

inv-101: Base of Skull Tumors (definition added in revision)

Revision-specific definitionBase of Skull Tumors: definition explicitly added to the policy as a proven indication grouping for definitive PBT

Examples included in revisionChordomas and chondrosarcomas cited as representative tumor types

Policy impactOperationalizes skull-base indications under Definitive Therapy criteria in the May 1, 2026 revision

inv-102: Central Nervous System Tumors (definition added in revision)

Revision-specific definitionCentral Nervous System Tumors: added to policy definitions and referenced as proven indications for definitive PBT when tumors are near critical anatomical structures

Anatomic examplesIncludes brain and spinal cord tumors with proximity to optic nerve, brainstem, or spinal cord

Policy impactAdded in May 1, 2026 revision to support expanded Definitive Therapy indications

inv-103: Head and Neck Cancer (definition added in revision)

DefinitionHead and Neck Cancer: cancers originating in tissues of the head and neck region (nasal cavity, sinuses, lips, mouth, salivary glands, throat, larynx), typically squamous cell origin

Policy additionPrimary head and neck cancers were added as proven definitive PBT indications when tumors are near critical anatomical structures and photon techniques cannot spare normal tissue

Clinical considerationsNCCN notes PBT may be appropriate when photon-based therapies cannot meet normal tissue dose constraints

inv-104: Definitive Therapy (definition updated in revision)

Updated definitionDefinitive Therapy: radiation treatments delivered with curative intent (updated in policy revision)

Policy implicationDefinitive Therapy indications expanded to include primary head & neck, CNS, mediastinal tumors, primary liver malignancies, and reirradiation under specified criteria

Documentation requirementFor Definitive Therapy indications, documentation must show tumors are near critical structures and photon techniques cannot adequately spare surrounding normal tissue

Revised exception-evaluation criterion to require comparison of treatment plans for PBT and photon-based radiation therapy (e.g., IMRT or SBRT) rather than explicit comparison among PBT, IMRT, and SBRT.

2026-05-01Documentation clarification

Added medical records documentation language emphasizing that federal/state/contractual requirements govern coverage, that medical records may be requested to assess clinical criteria, and that documentation does not guarantee coverage.

2026-05-01Supporting information update

Updated Clinical Evidence and References sections and archived previous policy version CS105NJ.Q.

Previous policy material has been archived and the Clinical Evidence and References sections were updated; the prior policy version CS105NJ.Q is noted as archived in the revision history for reference.