CurrentViva HealthPolicy s-029

Proton Beam Radiotherapy (PBRT) UR Guidelines 029 Policy and Procedure

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This policy establishes medical necessity and coverage criteria for proton beam radiotherapy (PBRT) for Viva Health members across applicable lines of business. It governs provider requests, required medical review, qualifying diagnoses, clinical circumstances, and associated CPT coding.

Policy Summary

PayerViva Health

PolicyProton Beam Radiotherapy (PBRT) coverage criteria

Policy CodePolicy s-029

Change TypeRevision 2

Effective Date01/01/2022

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.

4General PBRT medical necessity pathways

9Group 1 diagnosis categories or listed qualifying diagnoses

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CurrentViva HealthPolicy s-029

Proton Beam Radiotherapy (PBRT) UR Guidelines 029 Policy and Procedure

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

PolicyProton Beam Radiotherapy (PBRT) coverage criteria

Policy CodePolicy s-029

Change TypeRevision 2

Effective Date01/01/2022

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.

4General PBRT medical necessity pathways

9Group 1 diagnosis categories or listed qualifying diagnoses

Group 2 Medicare-only diagnosis categories

100%PBRT requests requiring medical review

15Listed PBRT-related CPT codes

Proton Beam Radiotherapy Coverage Criteria

General PBRT Medical Necessity

PBRT is covered when ALL of the following are met: at least one medical-necessity rationale applies, and the lesion-specific intent criteria are satisfied.

ALL of the following

At least ONE medical-necessity rationale
- The dose-volume histogram (DVH) demonstrates that one or more critical structures or organs would be protected by use of PBRT.
- The dose required to control or treat the tumor cannot be delivered without exceeding the tolerance of normal tissue.
- There is documented clinical rationale that doses generally thought to be above the level otherwise attainable with other radiation methods might improve control rates.
- There is documented clinical rationale that the higher levels of precision associated with PBRT compared with other radiation treatments are clinically necessary.
ONE applicable lesion-intent criterion
- For treatment of a primary lesion, the intent must be curative.
- For treatment of a metastatic lesion, at least ONE of the following must be met
  - There is an expectation of long-term benefit that could not have been attained with conventional therapy.> 2 years of life expectancy
  - 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.

Metastatic Lesions

For metastatic lesions, coverage requires at least ONE of the following criteria.

ONE of the following

There is an expectation of long-term benefit that could not have been attained with conventional therapy.> 2 years of life expectancy
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 — Commercial and Medicare

The following diagnoses are medically appropriate for both Commercial and Medicare lines of business. The applicable diagnosis must also meet the general PBRT medical-necessity and lesion-intent criteria.

ONE qualifying Group 1 diagnosis

Tumors that approach or are located at the base of the skull, including but not limited to chordomas, chondrosarcomas, and pituitary neoplasms.
Unresectable benign or malignant central nervous system tumors, including but not limited to primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations.
Intraocular melanomas.
Advanced-stage and unresectable malignant lesions of the head and neck.
Malignant lesions of the paranasal sinus and other accessory sinuses.

Group 2 Diagnoses — Medicare Only

The following diagnoses are medically appropriate for the Medicare line of business only. Coverage requires enrollment in a clinical trial, registry, or both, and documentation of the clinical trial and/or registry is required. All PBRT requests must be submitted for medical review regardless of whether the medical-necessity criteria in this policy appear to be met.

ALL of the following

ONE qualifying Group 2 diagnosis
- Unresectable lung cancers and upper abdominal or peridiaphragmatic cancers.
- Advanced-stage, unresectable pelvic tumors, including those with periaortic nodes or malignant lesions of the cervix.
- Left breast tumors.
- Unresectable pancreatic and adrenal tumors.

Coding and Billing Guidance

CPT CodesCPT

77263	Therapeutic Radiology Treatment Planning, Complex
77290	Therapeutic Radiology Simulation-Aided Field Setting, Complex. This code is typically reported only once per course of PBRT.
+77293	Respiratory Motion Management Simulation. List separately in addition to code for primary procedure. This add-on code cannot be billed on its own and should be billed with either CPT code 77295 or 77301.
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. This code is typically reported only once per course of PBRT.
77307	Teletherapy Isodose Plan, Complex
77300	Basic Radiation Dosimetry Calculation. This code can generally be billed once for each beam or arc up to a limit of ten.
77332	Treatment Devices, Design, and Construction, Simple
77333	Treatment Devices, Design, and Construction, Intermediate

1–10 of 18

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Metastatic-Lesion Long-Term Benefit

Applicable conditionMetastatic lesion

Long-term benefit thresholdGreater than 2 years of life expectancy

Conventional therapy requirementThe expected benefit could not have been attained with conventional therapy

Basic Radiation Dosimetry Billing Limit

CPT code77300 — Basic Radiation Dosimetry Calculation

Billing frequencyGenerally billed once for each beam or arc

Maximum quantity

Authorization and Documentation Requirements

Prior Authorization

Submit every PBRT request for medical review

All requests for coverage of PBRT must be sent for medical review regardless of whether the request appears to meet the medical necessity criteria in this policy.

Documentation Required

Support PBRT medical necessity

Submit documentation supporting the applicable PBRT medical necessity rationale. Documentation may include DVH evidence showing protection of critical structures or organs, normal-tissue tolerance limitations, clinical rationale for dose escalation or improved control, or clinical necessity for greater precision.

Documentation Required

Document curative intent for primary lesions

Proton Beam Radiotherapy Background

Proton beam radiotherapy (PBRT) is a radiation treatment modality that may be selected when its dose distribution or precision offers a clinically meaningful advantage over other radiation treatments. The policy recognizes potential benefit when PBRT can protect critical structures or organs, deliver tumor-control doses without exceeding normal-tissue tolerance, support clinically justified dose escalation, or provide precision that is clinically necessary.

Policy Summary

PayerViva Health

PolicyProton Beam Radiotherapy (PBRT) coverage criteria

Policy CodePolicy s-029

Change TypeRevision 2

Effective Date01/01/2022

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

Unresectable retroperitoneal sarcoma.

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.

Solid tumors in children.

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

Unresectable malignant lesions of the liver, biliary tract, anal canal, and rectum.

Non-metastatic prostate cancer.

The member is enrolled in a clinical trial, registry, or both, with documentation of the clinical trial and/or registry provided for coverage.

Up to a limit of ten beams or arcs

Continuing Medical Physical Consultation Reporting

CPT code77336 — Continuing Medical Physical Consultation

Standard reporting periodReported per week of therapy

Fraction-based reportingReported per 5 fractions of therapy

Document curative intent when PBRT is requested for a primary lesion. Primary-lesion treatment must have curative intent.

Documentation Required

Document the metastatic-lesion rationale

For metastatic lesions, document either the expectation of a long-term benefit greater than 2 years of life expectancy that could not have been attained with conventional therapy, or the expectation of complete eradication or improved duration of control that could not have been safely accomplished conventionally, supported by a PBRT dosimetric advantage.

Documentation Required

Provide Medicare Group 2 trial or registry documentation

For Medicare Group 2 diagnoses, provide documentation that the member is enrolled in a clinical trial, registry, or both. Documentation of the clinical trial and/or registry is required for coverage.

Denial Risk

Document a qualifying PBRT medical necessity rationale

Coverage requires at least one documented PBRT medical necessity rationale. Without documentation of an applicable rationale, coverage may not be approved.

Protection of one or more critical structures or organs shown by the dose volume histogram (DVH)
Inability to deliver the tumor-control dose without exceeding normal-tissue tolerance
Clinical rationale that a higher dose may improve control rates
Clinical rationale that PBRT precision is clinically necessary

Denial Risk

Avoid noncurative intent for primary lesions

Primary lesions must be treated with curative intent. A request for noncurative treatment of a primary lesion does not meet the policy requirement.

Denial Risk

Meet the metastatic-lesion criteria

For metastatic lesions, coverage requires either an expected long-term benefit greater than 2 years that could not have been attained with conventional therapy, or expected complete eradication or improved duration of control that could not have been safely accomplished conventionally and is supported by a PBRT dosimetric advantage.

Denial Risk

Document required Medicare Group 2 enrollment

Medicare Group 2 diagnoses are covered only when the member is enrolled in a clinical trial, registry, or both, with documentation of the clinical trial and/or registry. Missing this documentation creates a coverage risk.