CurrentViva Health PlanPolicy s-029

Proton Beam Radiotherapy (PBRT) Coverage Criteria

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Establishes medical-necessity and utilization-review requirements for proton beam radiotherapy for all lines of business, with additional clinical-trial or registry requirements for specified Medicare diagnoses.

Policy Summary

PayerViva Health Plan

PolicyProton Beam Radiotherapy (PBRT) Coverage Criteria

Policy CodePolicy s-029

Change TypeNo material change

Effective DateN/A

Last ReviewSep 15, 2026

Next Review DateN/A

Key ActionSend every PBRT coverage request for medical review, regardless of whether it appears to meet the medical-necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All LOBApplicability

18Listed CPT codes

Group 1Commercial and Medicare diagnosis pathway

Group 2

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CurrentViva Health PlanPolicy s-029

Proton Beam Radiotherapy (PBRT) Coverage Criteria

Customize your policy alerts

Sign up for vivahealthplan Policy s-029 alerts

Get alerted when Policy s-029 changes without checking for updates manually.

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Policy Summary

PayerViva Health Plan

PolicyProton Beam Radiotherapy (PBRT) Coverage Criteria

Policy CodePolicy s-029

Change TypeNo material change

Effective DateN/A

Last ReviewSep 15, 2026

Next Review DateN/A

Key ActionSend every PBRT coverage request for medical review, regardless of whether it appears to meet the medical-necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All LOBApplicability

18Listed CPT codes

Group 1Commercial and Medicare diagnosis pathway

Group 2

Medicare trial or registry pathway

100%Requests requiring medical review

Proton Beam Radiotherapy Coverage Criteria

General PBRT medical necessity

Covered when ANY of the following PBRT-specific medical-necessity rationales is met:

PBRT medical-necessity rationale

DVH protection: The Dose Volume Histogram confirms that one or more critical structures or organs are protected by use of PBRT
Normal-tissue tolerance: The dose needed to control or treat the tumor cannot be delivered without exceeding the tolerance of normal tissue
Higher dose rationale: There is documented clinical rationale that doses generally thought to be above the level otherwise attainable with other radiation methods might improve control rates
Precision rationale: There is documented clinical rationale that the higher levels of precision associated with PBRT compared with other radiation treatments are clinically necessary

Primary and metastatic lesion requirements

The applicable lesion-specific requirement must also be met:

Lesion status requirements

Primary lesion: For treatment of a primary lesion, treatment intent must be curativecurative intent
Metastatic lesion
- Long-term benefit: There is an expectation of a long-term benefit that could not have been attained with conventional therapy> 2 years life expectancy
- Eradication or control: There is an expectation of complete eradication or improved duration of control of the metastatic lesion that could not have been safely accomplished with conventional therapy, as evidenced by a dosimetric advantage for PBRT over other forms of radiation therapy

Group 1 diagnoses

Diagnosis must be one of the following Group 1 diagnoses. These diagnoses are medically appropriate for Commercial and Medicare lines of business:

Central nervous system tumors: Unresectable benign or malignant central nervous system tumors, including primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations
Intraocular melanomas
Skull-base tumors: Tumors that approach or are located at the base of the skull, including chordomas, chondrosarcomas, and pituitary neoplasms
Head and neck lesions: Advanced-stage and unresectable malignant lesions of the head and neck

Group 2 Medicare diagnoses

For the Medicare line of business only, the diagnosis must be one of the following and the member must be enrolled in a clinical trial, registry, or both. Documentation of the clinical trial and/or registry is required for coverage:

Group 2 Medicare diagnosis pathway

Group 2 diagnoses
- Lung or upper abdominal cancer: Unresectable lung cancers and upper abdominal or peri-diaphragmatic cancers
- Pelvic tumors: Advanced-stage, unresectable pelvic tumors, including those with periaortic nodes or malignant lesions of the cervix
- Breast tumor: Left breast tumors
- Pancreatic or adrenal tumor:

Applicable Procedure Codes

CPT CodesCPT

77263	Therapeutic Radiology Treatment Planning, Complex
77290	Therapeutic Radiology Simulation-Aided Field Setting, Complex
+77293	Respiratory Motion Management Simulation; list separately in addition to code for primary procedure
77321	Special Teletherapy Port Plan, Particles, Hemibody, Total Body
77295	Therapeutic Radiology Simulation-Aided Field Setting, 3-dimensional
77301	Intensity Modulation Radiotherapy Plan, Including DVH
77307	Teletherapy Isodose Plan, Complex
77300	Basic Radiation Dosimetry Calculation
77332	Treatment Devices, Design, and Construction, Simple
77333	Treatment Devices, Design, and Construction, Intermediate

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Submission Requirements and Denial Risks

Prior Authorization

Medical Review Required for Every Request

Every request for coverage of proton beam radiotherapy (PBRT) must be sent for medical review, regardless of whether the request appears to meet the medical-necessity criteria in this policy.

Documentation Required

DVH and Clinical Rationale Required

Submit the dose-volume histogram (DVH) and a documented clinical rationale explaining why PBRT is required for the member’s treatment.

Document protection of one or more critical structures or organs by PBRT, or that conventional radiation would exceed normal-tissue tolerance.
If applicable, document that PBRT may improve tumor-control rates through doses above those otherwise attainable, or that PBRT’s greater precision is clinically necessary.

Policy Background

Proton beam radiotherapy (PBRT) is evaluated for its potential to protect critical structures and organs, reduce exposure to normal tissue, enable tumor-control doses that may not be safely delivered with other radiation methods, and provide clinically necessary treatment precision. Coverage is focused on selected lesions and tumors when the clinical record establishes a PBRT-specific rationale and satisfies the applicable lesion and diagnosis requirements.

Key Terms

Dose Volume Histogram (DVH)

DefinitionA Dose Volume Histogram (DVH) is used to evaluate the dose delivered to critical structures or organs.

PurposeThe DVH confirms that one or more critical structures or organs are protected by the use of proton beam radiotherapy (PBRT).

Coverage documentationSubmit the DVH when relying on protection of one or more critical structures or organs to support PBRT coverage.

Policy Summary

PayerViva Health Plan

PolicyProton Beam Radiotherapy (PBRT) Coverage Criteria

Policy CodePolicy s-029

Change TypeNo material change

Effective DateN/A

Last ReviewSep 15, 2026

Next Review DateN/A

Key ActionSend every PBRT coverage request for medical review, regardless of whether it appears to meet the medical-necessity criteria.

SourceLink

On This Page

Paranasal sinus lesions: Malignant lesions of the paranasal sinus and other accessory sinuses

Retroperitoneal sarcoma: Unresectable retroperitoneal sarcoma

Spinal tumors: Primary or metastatic tumors of the spine where spinal cord tolerance may be exceeded with conventional treatment or where the spinal cord has previously been irradiated

Pediatric solid tumors: Solid tumors in children

Unresectable pancreatic and adrenal tumors

Skin cancer with invasion: Skin cancer with macroscopic perineural or cranial nerve invasion of the skull base

Liver, biliary, anal, or rectal lesion: Unresectable malignant lesions of the liver, biliary tract, anal canal, and rectum

Prostate cancer: Non-metastatic prostate cancer

Trial or registry enrollment: The member is enrolled in a clinical trial, registry, or both

Documentation Required

Document Treatment Intent and Lesion Status

The request must identify whether the lesion is primary or metastatic and document the treatment intent and applicable clinical criteria.

For a primary lesion, document curative treatment intent.
For a metastatic lesion, document the applicable long-term-benefit or complete-eradication/improved-control rationale and the relevant comparison with conventional therapy.

Documentation Required

Clinical Trial or Registry Documentation Required

For Medicare Group 2 diagnoses, coverage requires enrollment in a qualifying clinical trial, registry, or both. Submit documentation of the applicable clinical trial and/or registry with the PBRT request.

This Medicare-only requirement applies to Group 2 diagnoses, including unresectable lung or upper abdominal/peri-diaphragmatic cancers, advanced unresectable pelvic tumors, left breast tumors, unresectable pancreatic or adrenal tumors, selected skull-base perineural/cranial-nerve skin cancers, selected unresectable liver, biliary tract, anal canal, or rectal malignancies, and non-metastatic prostate cancer.

Documentation Required

Diagnosis and Group Classification Required

Submit documentation supporting the diagnosis and its classification as a Group 1 or Group 2 diagnosis under the PBRT guideline.

Group 1 includes qualifying central nervous system tumors; intraocular melanomas; skull-base tumors; advanced unresectable head-and-neck or paranasal-sinus lesions; unresectable retroperitoneal sarcoma; qualifying primary or metastatic spine tumors; and solid tumors in children.
Group 2 includes the Medicare-only diagnoses listed in this guideline and is covered only when the member is enrolled in a clinical trial, registry, or both.

Denial Risk

Insufficient PBRT Medical Rationale

A request is at risk for denial when it does not include a PBRT-specific medical rationale. General statements that radiation is needed are insufficient without documentation of why PBRT provides a clinically necessary advantage.

Provide the DVH or other dosimetric evidence showing critical-structure protection or avoidance of normal-tissue tolerance limits.
Alternatively, document a PBRT-specific rationale involving improved control from otherwise unattainable dose levels or clinically necessary precision compared with other radiation treatments.

Denial Risk

Treatment Intent or Metastatic Criteria Not Met

The request is at risk for denial when treatment intent or metastatic-lesion criteria are not met. Primary lesions must have curative intent; metastatic lesions must satisfy the policy’s long-term-benefit or control criteria.

Primary lesion: denial risk exists when the documented intent is not curative.
Metastatic lesion: document an expected benefit greater than 2 years that could not be attained with conventional therapy, or expected complete eradication or improved duration of control that could not have been safely accomplished conventionally, supported by a PBRT dosimetric advantage.

Denial Risk

Diagnosis or Medicare Trial Requirement Not Met

The request is at risk for denial when the diagnosis falls outside an applicable diagnosis group or when Medicare Group 2 clinical-trial or registry requirements are not satisfied.

Document that the diagnosis meets a listed Group 1 or Group 2 category.
For Medicare Group 2 coverage, provide required clinical trial, registry, or combined trial-and-registry enrollment documentation; absence of that documentation supports denial.