LCD/NCD Portal

L29263

 

PROTON BEAM RADIOTHERAPY

 

10/01/2011

 

Indications and Limitations of Coverage and/or Medical Necessity

• In general, proton beam radiotherapy is NOT indicated for cancers that are widely disseminated, such as

o leukemias,

o have hematogenous metastases or

o As a short term palliative procedure.

• The intent of treatment should be curative.

• If proton beam radiotherapy is used for a patient with metastic disease,

o evidence should be provided to justify the expectation of a long-term benefit (> 2y), as well as

o Evidence of a dosimetric advantage for proton beam radiotherapy over other forms of radiation therapy.

• Proton beam therapy will be considered medically reasonable and necessary for the following conditions (Group #1 of ICD-9-CM Codes that Support Medical Necessity):

o Group #1 Conditions

 Benign or malignant conditions otherwise not suitable for intensity modulated radiation therapy (IMRT) or 3-dimensional conformal therapy involving the base of the skull or axial skeleton, including but not limited to chordomas and chondrosarcomas.

 Solid tumors in children up to age 18.

 Benign or malignant central nervous system tumors to include primary and variant forms of medulloblastoma, astrocytoma, glioblastoma, arteriovenous malformations, acoustic neuroma craniopharyngioma, benign and atypical meningiomas and pineal gland tumors.

 Intraocular melanomas

o Because many radiological oncologists believe that proton beam therapy is a legitimate treatment option in certain circumstances where 3-dimensional conformal or intensity modulated radiation therapy (IMRT) is deemed medically necessary, First Coast Service Options, Inc. (FCSO) will consider proton beam therapy as medically reasonable and necessary for certain other conditions (i.e., Group #2 of ICD-9-CM Codes that Support Medical Necessity) not listed above, as long as the following criteria are met:

 Either #1, #2, or #3 must be present

And

 Either #4 or #5 must be present

And

 #6 must always be present.

• 1. When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with other indicated methods

• 2. When there is a reason to believe that doses generally thought to be above the level otherwise attainable with other methods might improve control rates

• 3. In circumstances when the higher levels of precision associated with proton beam therapy as compared to other radiation methods are necessary, i.e clinically relevant

• 4. For the treatment of primary lesions, the intent of treatment must be curative

• 5. For the treatment of metastatic lesions, there must be

o The expectation of a long-term benefit (> 2y) that could not have been attained with conventional therapy.

o The expectation of a complete eradication of the metastatic lesion that could not have been safely accomplished with conventional therapy, as evidenced by a dosimetric advantage for proton beam radiotherapy over other forms of radiation therapy.

• 6. The patient’s record demonstrates why Proton beam radiotherapy is considered the treatment of choice for the individual patient. Specifically, the record must address the lower risk to normal tissue, the lower risk of disease recurrence, and the advantages of the treatment over IMRT or 3-dimensional conformal radiation. Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control must be maintained.

 If the above provisions are met and the patient is treated in a protocol that is designed for evidence development and for future publication, it is expected that future published data will support an outcome advantage for Medicare patients for continued coverage of the specific diagnosis.

• The protocol in and by itself does not constitute criteria for coverage.

• The presence of an Institutional Review Board review, when appropriate and patient informed consent are also expected.

o Proton beam treatment of the following conditions may be considered medically reasonable and necessary only if the above criteria are met as specified (see Group #2 of the ICD-9 Codes that Support Medical Necessity).

o Group #2 Conditions

 Malignant lesions of the head and neck when the intent of treatment is to be curative.

 Malignant lesions of the Para nasal sinus, and other accessory sinuses

 Malignant lesions of the prostate

 Malignant advanced stage, non-metastatic tumors of the bladder

 Advanced pelvic tumors including malignant lesions of the cervix

 Left breast tumors

 Pancreatic and adrenal tumors

 Skin cancer with perineural/cranial nerve invasion

 Unresectable retroperitoneal sarcoma and extremity sarcoma

 Cancers of the lung and upper abdominal/peri-diaphragmatic cancers

 Malignant lesions of the liver, biliary tract, anal canal and rectum

• Note: All other indications are NOT considered reasonable and necessary and will be denied.

• If the patient cannot clearly meet the criteria for coverage but desires Proton beam radiotherapy based on a marketed theoretical advantage, the claim should be billed with the appropriate modifier appended to the treatment delivery code.

 

CPT/HCPCS Codes

 

 

 

 

Note: Other CPT/HCPCS codes may be appropriate (i.e., treatment planning, dosimetry, port films, etc.)

77520 PROTON TREATMENT DELIVERY; SIMPLE, WITHOUT COMPENSATION

77522 PROTON TREATMENT DELIVERY; SIMPLE, WITH COMPENSATION

77523 PROTON TREATMENT DELIVERY; INTERMEDIATE

77525 PROTON TREATMENT DELIVERY; COMPLEX

 

 

ICD-9 Codes that Support Medical Necessity

 

 

Group #1 Listing

 

170.0 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE

170.1 MALIGNANT NEOPLASM OF MANDIBLE

170.2 MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX

170.3 MALIGNANT NEOPLASM OF RIBS STERNUM AND CLAVICLE

170.4 MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB

170.5 MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB

170.6 MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND COCCYX

170.7 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB

170.8 MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB

170.9 MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED

171.0 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

171.2 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER

171.3 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP

171.4 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF THORAX

171.5 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF ABDOMEN

171.6 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF PELVIS

171.7 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF TRUNK UNSPECIFIED

171.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CONNECTIVE AND OTHER SOFT TISSUE

171.9 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED

189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS

190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

190.1 MALIGNANT NEOPLASM OF ORBIT

190.2 MALIGNANT NEOPLASM OF LACRIMAL GLAND

190.3 MALIGNANT NEOPLASM OF CONJUNCTIVA

190.4 MALIGNANT NEOPLASM OF CORNEA

190.5 MALIGNANT NEOPLASM OF RETINA

190.6 MALIGNANT NEOPLASM OF CHOROID

190.7 MALIGNANT NEOPLASM OF LACRIMAL DUCT

190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE

190.9 MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED

191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES

191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE

191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE

191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE

191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE

191.5 MALIGNANT NEOPLASM OF VENTRICLES

191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS

191.7 MALIGNANT NEOPLASM OF BRAIN STEM

191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN

191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE

192.0 MALIGNANT NEOPLASM OF CRANIAL NERVES

192.1 MALIGNANT NEOPLASM OF CEREBRAL MENINGES

192.2 MALIGNANT NEOPLASM OF SPINAL CORD

192.3 MALIGNANT NEOPLASM OF SPINAL MENINGES

192.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM

194.3 MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

194.4 MALIGNANT NEOPLASM OF PINEAL GLAND

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

225.0 BENIGN NEOPLASM OF BRAIN

225.1 BENIGN NEOPLASM OF CRANIAL NERVES

225.2 BENIGN NEOPLASM OF CEREBRAL MENINGES

225.3 BENIGN NEOPLASM OF SPINAL CORD

225.4 BENIGN NEOPLASM OF SPINAL MENINGES

225.8 BENIGN NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM

227.3 BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

227.4 BENIGN NEOPLASM OF PINEAL GLAND

237.0 NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

237.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF PINEAL GLAND

237.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD

237.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES

747.81 CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM

 

Group #2 Listing

141.0 MALIGNANT NEOPLASM OF BASE OF TONGUE

142.0 MALIGNANT NEOPLASM OF PAROTID GLAND

142.1 MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND

142.2 MALIGNANT NEOPLASM OF SUBLINGUAL GLAND

143.0 MALIGNANT NEOPLASM OF UPPER GUM

143.1 MALIGNANT NEOPLASM OF LOWER GUM

144.0 MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH

144.1 MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH

144.8 MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH

144.9 MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED

145.0 MALIGNANT NEOPLASM OF CHEEK MUCOSA

145.1 MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH

145.2 MALIGNANT NEOPLASM OF HARD PALATE

145.3 MALIGNANT NEOPLASM OF SOFT PALATE

145.4 MALIGNANT NEOPLASM OF UVULA

145.5 MALIGNANT NEOPLASM OF PALATE UNSPECIFIED

145.6 MALIGNANT NEOPLASM OF RETROMOLAR AREA

145.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH

145.9 MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED

146.0 MALIGNANT NEOPLASM OF TONSIL

146.1 MALIGNANT NEOPLASM OF TONSILLAR FOSSA

146.2 MALIGNANT NEOPLASM OF TONSILLAR PILLARS (ANTERIOR) (POSTERIOR)

146.3 MALIGNANT NEOPLASM OF VALLECULA EPIGLOTTICA

146.4 MALIGNANT NEOPLASM OF ANTERIOR ASPECT OF EPIGLOTTIS

146.5 MALIGNANT NEOPLASM OF JUNCTIONAL REGION OF OROPHARYNX

146.6 MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX

146.7 MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX

146.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF OROPHARYNX

146.9 MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE

147.0 MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX

147.1 MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX

147.2 MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX

147.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX

147.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX

147.9 MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE

148.0 MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX

148.1 MALIGNANT NEOPLASM OF PYRIFORM SINUS

148.2 MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD HYPOPHARYNGEAL ASPECT

148.3 MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL

148.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX

148.9 MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE

149.0 MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED

149.1 MALIGNANT NEOPLASM OF WALDEYER'S RING

154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION

154.1 MALIGNANT NEOPLASM OF RECTUM

154.2 MALIGNANT NEOPLASM OF ANAL CANAL

154.3 MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE

154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY

155.1 MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS

155.2 MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

157.0 MALIGNANT NEOPLASM OF HEAD OF PANCREAS

157.1 MALIGNANT NEOPLASM OF BODY OF PANCREAS

157.2 MALIGNANT NEOPLASM OF TAIL OF PANCREAS

157.3 MALIGNANT NEOPLASM OF PANCREATIC DUCT

157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

157.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS

157.9 MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

158.0 MALIGNANT NEOPLASM OF RETROPERITONEUM

160.0 MALIGNANT NEOPLASM OF NASAL CAVITIES

160.1 MALIGNANT NEOPLASM OF AUDITORY TUBE MIDDLE EAR AND MASTOID AIR CELLS

160.2 MALIGNANT NEOPLASM OF MAXILLARY SINUS

160.3 MALIGNANT NEOPLASM OF ETHMOIDAL SINUS

160.4 MALIGNANT NEOPLASM OF FRONTAL SINUS

160.5 MALIGNANT NEOPLASM OF SPHENOIDAL SINUS

160.8 MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES

160.9 MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED

161.0 MALIGNANT NEOPLASM OF GLOTTIS

161.1 MALIGNANT NEOPLASM OF SUPRAGLOTTIS

161.2 MALIGNANT NEOPLASM OF SUBGLOTTIS

161.3 MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES

161.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX

161.9 MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED

162.0 MALIGNANT NEOPLASM OF TRACHEA

162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS

162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG

162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG

162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG

162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

164.0 MALIGNANT NEOPLASM OF THYMUS

164.1 MALIGNANT NEOPLASM OF HEART

164.2 MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM

164.3 MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM

173.00 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP

173.01 BASAL CELL CARCINOMA OF SKIN OF LIP

173.02 SQUAMOUS CELL CARCINOMA OF SKIN OF LIP

173.09 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP

173.10 UNSPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS

173.11 BASAL CELL CARCINOMA OF EYELID, INCLUDING CANTHUS

173.12 SQUAMOUS CELL CARCINOMA OF EYELID, INCLUDING CANTHUS

173.19 OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS

173.20 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

173.21 BASAL CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

173.22 SQUAMOUS CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

173.29 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

173.30 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

173.31 BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

173.32 SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

173.39 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

173.40 UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK

173.41 BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK

173.42 SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF NECK

173.49 OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK

173.50 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM

173.51 BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM

173.52 SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM

173.59 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM

173.60 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER

173.61 BASAL CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER

173.62 SQUAMOUS CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER

173.69 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER

173.70 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP

173.71 BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP

173.72 SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP

173.79 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP

173.80 UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN

173.81 BASAL CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN

173.82 SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN

173.89 OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN

173.90 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED

173.91 BASAL CELL CARCINOMA OF SKIN, SITE UNSPECIFIED

173.92 SQUAMOUS CELL CARCINOMA OF SKIN, SITE UNSPECIFIED

173.99 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED

174.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST

174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST

174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST

174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST

174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST

174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST

174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST

180.0 MALIGNANT NEOPLASM OF ENDOCERVIX

180.1 MALIGNANT NEOPLASM OF EXOCERVIX

180.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CERVIX

183.0 MALIGNANT NEOPLASM OF OVARY

184.0 MALIGNANT NEOPLASM OF VAGINA

185 MALIGNANT NEOPLASM OF PROSTATE

188.0 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER

188.1 MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER

188.2 MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER

188.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER

188.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER

188.5 MALIGNANT NEOPLASM OF BLADDER NECK

188.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE

188.7 MALIGNANT NEOPLASM OF URACHUS

188.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER

188.9 MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED

193 MALIGNANT NEOPLASM OF THYROID GLAND

194.1 MALIGNANT NEOPLASM OF PARATHYROID GLAND

195.1 MALIGNANT NEOPLASM OF THORAX

195.2 MALIGNANT NEOPLASM OF ABDOMEN

195.3 MALIGNANT NEOPLASM OF PELVIS

197.0 SECONDARY MALIGNANT NEOPLASM OF LUNG

197.7 MALIGNANT NEOPLASM OF LIVER SECONDARY

 

 

Documentation Requirements

• Documentation must support that the services were performed, including the condition requiring proton beam therapy and why this technology was medically necessary as opposed to conventional radiation therapy.

• The medical record must support that all requirements listed under Indications and Limitations of Coverage and/or Medical Necessity have been met.

• The medical record should contain all of the necessary information to process a claim for these services including supporting information about the indications for a particular procedure.

Treatment Logic

• Proton beam radiotherapy is a type of particle beam radiation therapy that delivers high dose radiation to a localized site.

• Proton beams theoretically deposit less radiation in normal non-targeted tissues than conventional radiation therapy and have been used to escalate the radiation dose to diseased tissues while minimizing damage to adjacent normal tissues.

• Historically, proton beam radiotherapy has most commonly been used for tumors that are difficult or dangerous to treat with surgery or for tumors that are located next to vital structures, where administration of adequate doses of conventional radiation is difficult or impossible.

 

Sources of Information and Basis for Decision

 

American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice. Role of radiation therapy. Retrieved from the web on 11/15/2005 at www.guideline.gov.

 

American College of Radiation Oncology (ACRO), Practice Management Guide; Proton Therapy in the United States (2004).

 

Barker, FG, Butler, WE, Lyons, S, Cascio, E, Ogilvy, CS, Loeffler, JS, Chapman, PH (2003). Dose-volume prediction of radiation-related complications after proton beam radiosurgery for cerebral arteriovenous malformations. Journal of Neurosurgery, 99(2): 222-3; discussion 223-4.

 

Baumert BG, Lomax AJ, Miltchev V, Davis JB (2001). A comparison of dose distributions of proton and photon beams in stereotactic conformal radiotherapy of brain lesions. International Journal of Radiation Oncology, Biology, Physics, 49(5): 1439-49.

 

Bush DA, Hillebrand DJ, Slater JM, Slater JD. High-Dose Proton Radiotherapy of Hepatocellular Carcioma: Preliminary Results of a Phase II Trial. Gastroenterology 2005:128:S189-S193

 

Cozzi L, Fogliata A, Lomax A, Bolsi A. A treatment planning comparison of 3D conformal therapy, intensity modulated photon therapy, and proton therapy for treatment of advanced head and neck tumours. Radiotherapy and Oncology 61: 287-297, 2001.

 

Hug EB, Nevinny-Stickel M, Fuss M, Miller DW, Schaefer RA, Slater JD. Conformal Proton Radiation Treatment for Retroperitoneal Neuroblastoma: Introduction of a Novel Technique. Medical and Pediatric Oncology 37: 36-41, 2001.

 

Kawashima M, Furuse J, Nishio T, Konishi M, Ishii H, Kinoshita T, Nagase M, Nihei K, Ogino T. Phase II Study of Radiotherapy Employing Proton Beam for Hepatocellular Carcinoma. J Clin. Oncol., Vol. 23(9)1839-1846, 2005

 

Kirsch DG, Tarbell NJ (2004). New technologies in radiation therapy for pediatric brain tumors: the rational for proton radiation therapy. Pediatric Blood Cancer, 42(5): 461-4.

 

National Cancer Institute, Fact Sheet [On-line]. Retrieved from the web on 12/14/05 and available at: www.cancer.gove/cancertopics/factsheet/Therapy/radiation.

 

Noel G, Habrand JL, Mammar H, Pontvert D, Haie-Meder C, Hasboun D, Moisson P, Ferrand R, Beaudre A, Boisserie G, Gaboriaud G, Mazai A, Kerody K, Schlienger M, Mazeron JJ. Combination of Photon and Proton Radiation Therapy for Chordomas and Chondrosarcomas of the Skull Base: The Centre de Protontherapie D’Orsay Experience. Int. J. Radiat. Oncol. Biol. Phys., 51(2)392-398, 2001.

 

Rundle P, Singh AD, Rennie I (2006). Proton beam therapy for iris melanoma: a review of 15 cases. Eye, Retrieved from PubMed at www.ncbi.nlm.nih.gov on March 31, 2006.

 

Slater JD. Clinical Applications of Proton Radiation Treatment at Loma Linda University: Review of a Fifteen-year Experience. Technology in Cancer Research and Treatment, Vol. 5(2) 81-89, April 2006.

 

Weber DC, Rutz HP, Pedroni ES, Bolsi A, Timmermann B, Verwey J, Lomax AJ, Goitein G. Results of Spot-Scanning Proton Radiation Therapy for Chordoma and Chondrosarcoma of the Skull Base: The Paul Scherrer Institut Experience. Int. J. Radiat. Oncol. Biol. Phys., Vol. 63(2)401-409, 2005.

 

Weber DC, Chan AW, Bussiere MR, Harsh GR, Ancukiewicz M, Barker FG, Thornton AT, Martuza RL, Nadol JB, Chapman PH, Loeffler JS. Proton Beam Radiosurgery for Vestibular Schwannoma: Tumor Control and Cranial Nerve Toxicity. Neurosurgery 53: 577-588, 2003.

 

10/01/2011

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L29263 Proton Beam Radiotherapy