Proton Beam Radiation Therapy (for New Mexico Only)
Defines UnitedHealthcare medical policy for proton beam radiation therapy (PBT/PBRT) for members in New Mexico aged 19 and older and indicates PBT is covered without prior review for individuals under 19. Specifies indications considered proven and medically necessary and criteria for exceptions.
Primary head and neck cancers were added as a proven and medically necessary indication for definitive PBT when tumors are near critical anatomical structures and photon techniques cannot achieve adequate normal tissue sparing.
Primary central nervous system tumors were added as a proven and medically necessary indication for definitive PBT when tumors are near critical structures and photon techniques cannot achieve adequate normal tissue sparing.
Primary mediastinal tumors (e.g., thymomas, mediastinal lymphomas, thoracic sarcomas) were added as proven indications for PBT.
Reirradiation was specified as an indication when prior radiation was to the same site and photon techniques cannot spare surrounding normal tissue.
Coverage language for primary liver malignancies was broadened to 'primary liver malignancies, such as hepatocellular carcinoma and intrahepatic cancer (localized, unresectable)' with tissue-sparing documentation requirements.
Exception evaluation criteria were revised to require comparison of treatment plans for PBT and photon-based radiation therapy (such as IMRT or SBRT) rather than separately listing IMRT and SBRT.
Definitions were added for Base of Skull Tumors, Central Nervous System Tumors, and Head and Neck Cancer; the definition of 'Definitive Therapy' was updated.
CPT/HCPCS codes 77385, 77386, G6015, G6016, and G6017 were removed from the applicable codes list.
Medical records documentation may be required to assess whether the member meets clinical criteria and must fully support medical necessity; documentation should be legible and available upon request.
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