Proton Beam Radiation Therapy (for Tennessee Only)
Tennessee-specific medical policy for UnitedHealthcare Medicaid and CoverKids governing coverage and medical necessity criteria for proton beam radiation therapy (PBT) for beneficiaries aged 19 and older; PBT is covered without further review for individuals younger than 19.
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 spare surrounding normal tissue.
Primary Central Nervous System Tumors (e.g., brain or spinal cord) were added as a proven and medically necessary indication for definitive PBT when tumors are near critical structures and photon techniques cannot spare surrounding normal tissue.
Primary mediastinal tumors (e.g., thymomas, mediastinal lymphomas, thoracic sarcomas) were added to the proven indications list.
Reirradiation was added as a proven indication when prior radiation was to the same anatomical site and documentation shows photon techniques cannot spare surrounding normal tissue.
The policy replaced a narrow HCC indication with a broader category of primary liver malignancies (hepatocellular carcinoma and intrahepatic cancer) for curative-intent PBT when photon techniques cannot spare surrounding normal tissue and other locoregional therapies are contraindicated or not feasible.
Evaluation of exception requests now requires comparison of treatment plans for PBT and photon-based radiation therapy (such as IMRT or SBRT) rather than a three-way comparison phrased previously.
Removed CPT/HCPCS codes 77385, 77386, G6015, G6016, and G6017 from the Applicable Codes section.
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