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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-77260-18

Original Effective Date: 06/15/02

Reviewed: 12/01/16

Revised: 12/15/16

Subject: Proton Beam Therapy

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Proton beams are charged particle beams used as an alternative to conventional x-rays, gamma-rays, and other types of photon irradiation in the treatment of malignancies. Proton beam therapy requires specialized equipment in the form of accelerators (cyclotrons, synchrotrons, synchrocyclotrons, or linear accelerators) that can generate a beam of proton particles. Accurate localization of the malignancy by using tomographic scanning (with x-ray and/or magnetic resonance imaging), and precise and reproducible positioning (relative to the beam) and immobilization of the body during both tomographic scanning and treatment is also required. This type of radiation therapy allows for minimal scatter as particulate beams pass through tissue and disposes ionizing energy at precise depths (i.e., the Bragg peak), thereby minimizing tissue damage around the area being treated.

Proton beam therapy has been found to be useful in the treatment of tumors that are localized and have not spread to distant areas of the body and are not amenable to surgical excision or other conventional forms of radiation treatment. This includes tumors that are in close proximity to vital structures, which make surgery or conventional radiation therapy difficult or impossible. Because proton beam therapy can be used to precisely focus radiation on specific areas with little exposure to adjacent tissues, proton beam may be useful for treatment of tumors located near radio-sensitive structures. Proton beam therapy can be given with or without stereotactic techniques. Stereotactic approaches are frequently used for uveal and skull based tumors. Like conventional radiation therapy, proton beam therapy treatments may be delivered in a few days or up to several weeks.

Coverage for proton beam therapy is subject to the member’s benefit terms, limitations and maximums. The member’s contract language must be reviewed to determine coverage for proton beam therapy. Please note, this policy contains a specific “Comparative Effectiveness” coverage analysis section for Proton Beam Therapy in the treatment of Prostate Cancer. For Florida Blue policies with a definition of Medical Necessity that contains the comparative effectiveness language, coverage for Proton Beam Therapy will be determined through application of the Comparative Effectiveness section of this medical policy.

Proton Beam Therapy Research Summary

POSITION STATEMENT:

NOTE: Coverage for proton beam therapy is subject to the member’s benefit terms, limitations and maximums. Some contracts may exclude coverage for proton beam therapy. Refer to specific contract language to determine coverage. Medical records may be required to be submitted for medical review.

NOTE: For member contracts that include comparative effectiveness language, the relative cost of proton beam therapy compared to other forms of treatment may be considered in the medical necessity determination as more particularly described in the section below entitled Comparative Effectiveness Analysis.

While proton beam therapy has been used for cancer treatment, there is limited published clinical evidence demonstrating its clinical benefit over conventional forms of radiation therapy (e.g., IMRT, brachytherapy). Because proton therapy is generally more costly than alternative therapies, comparative effectiveness evidence is needed on the safety, benefits, and health outcomes compared to other conventional forms of radiation therapy.

The intent of proton beam therapy is curative, with an expectation of a long-term benefit (greater than 2 years).

Proton beam therapy meets the definition of medical necessity for the following indications:

Arteriovenous Malformation (AVM)

Proton beam therapy meets the definition of medical necessity for the following:

Intracranial AVM not amenable to surgical excision or other conventional forms of treatment; OR

• Intracranial AVM adjacent to critical structures such as the optic nerve, brain stem or spinal cord

Central Nervous System (CNS) Tumors

Proton beam therapy meets the definition of medical necessity for the following:

Primary or metastatic CNS malignancies, including, but not limited to gliomas (Note: ALL of the following criteria must be met.):

When adjacent to critical structures such as the optic nerve, brain stem, or spinal cord; AND

• When other standard radiation techniques such as IMRT or standard stereotactic modalities would not reduce the risk of radiation damage to the critical structure

Chordoma/Chondrosarcoma

Proton beam therapy meets the definition of medical necessity for the following:

• As postoperative therapy for members who have undergone biopsy or partial resection of a chordoma or low-grade (I or II) chondrosarcoma of the basisphenoid region (e.g. skull-base chordoma or chondrosarcoma), cervical spine, or sacral/lower spine and have residual, localized tumor without evidence of metastasis

Melanoma (Ocular Melanoma)

Proton beam therapy meets the definition of medical necessity for the following:

• As primary therapy for melanoma of the uveal tract (including the iris, choroid, or ciliary body) involving tumors of up to 24 mm in largest diameter and 14 mm in height, and with no evidence of metastasis or extrascleral extension

(Note: Particularly when plaque brachytherapy is not a feasible option)

Solid Tumors in Children

Proton beam therapy meets the definition of medical necessity for solid tumors in children below age 18.

Other

Proton beam therapy meets the definition of medical necessity for the following indications when ALL of the below criteria (a, b, c, and d) are met:

• Benign or malignant conditions involving the base of the skull or axial skeleton

• Left breast tumors

• Lung cancer

• Malignant lesions of liver

• Peri-diaphragmatic cancer

• Unresectable extremity sarcoma

• Unresectable retroperitoneal sarcoma

• Upper abdominal cancer

Criteria

a) The disease is primary and non-metastatic, that is confined regionally to the primary organ (including regional lymph nodes); AND

b) Dosimetric treatment planning comparisons between IMRT and proton beam therapy have been made; AND

c) Dosimetric treatment planning with IMRT predicts the radiation dose to adjacent organs would be exceeded; AND

d) Dosimetric treatment planning with proton beam therapy is able to reduce adjacent organ radiation exposure to a safe level

Prostate Cancer

Note: With regard to the use of proton beam therapy for prostate cancer, even if the use of proton beam therapy meets the general medical necessity criteria below, then coverage is subject to the additional analysis of the comparative effectiveness, if applicable, in accordance with the section below entitled Comparative Effectiveness Analysis for Proton Beam Therapy in the Treatment of Prostate Cancer.

Proton beam therapy meets the definition of medical necessity for the treatment of prostate cancer when the below medical necessity 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 (e.g., 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:

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

• 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 member’s record must demonstrates why proton beam therapy is considered the treatment of choice for the member. Specifically, the notes in the member’s medical 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 as part of the member’s medical record (the medical record may be requested as part of the review process).

7. Florida Blue strongly supports (but does not require) ASTRO’s recommendation that members with prostate cancer being treated with Proton Beam Therapy enroll either in an Institutional Review Board (IRB) approved clinical trial or in a multi-institutional patient registry, for evidence development. Documentation in the member’s medical record must note the reason why the member is unable to enroll in either an Institutional Review Board (IRB) approved clinical trial or in a multi-institutional patient registry for evidence development.

As an alternative to meeting the seven (1-7) factors above, the treatment will be considered to meet the definition of medical necessity and meeting the first six (1-6) factors above if the member is enrolled in an IRB approved clinical trial or in a multi-institutional patient registry treated in a protocol that is designed for evidence development for proton beam therapy for prostate cancer treatment.

Proton Beam Therapy and IMRT

Proton beam therapy used in conjunction with intensity-modulated radiation therapy (IMRT) is considered experimental or investigational, as there is insufficient evidence to support the combined use of proton beam therapy and IMRT on health outcomes. Comparative effectiveness studies including randomized controlled trials are needed to demonstrate the safety and long-term efficacy of proton beam therapy used in conjunction with IMRT.

For all other indications not listed above, proton beam therapy is considered experimental or investigational, as there is insufficient evidence to support conclusions regarding the effect of proton beam therapy on health outcomes.

COMPARATIVE EFFECTIVENESS ANALYSIS:

This section only applies to member contracts that contain a comparative effectiveness analysis within the definition of Medical Necessity. This may apply to member contracts that were issued or renewed on or after January 1, 2014.

If a service meets the medical necessity criteria set forth above in the Position Statement, then an analysis under this comparative effectiveness section should be applied, solely for coverage and payment purposes. Initially, this analysis should determine if: 1.) There is an alternate service available that produces the same or similar outcomes and/or 2.) The same service as requested or performed can be rendered at a different location of service. If there is no alternative service that produces the same or similar outcomes nor is there a different location at which the services could be rendered, then no further comparative effectiveness analysis need be completed and the service will be deemed to have met the definition of medical necessity. If, however, there are alternative services that produce the same or similar outcomes and/or there is a different location of service at which the services can be rendered, then a comparative effectiveness analysis must be conducted to determine if: a.) The same service rendered at a different location; or b.) An alternate service(s) is/are less costly. If the answer is yes, then the requested service does satisfy the requirements of this comparative effectiveness analysis and does not meet the medical necessity requirements for coverage and payment purposes. The comparative effectiveness analysis is represented by the following flowchart:

Application of Comparative Effectiveness Analysis for Proton Beam Therapy for the Treatment of Prostate Cancer

A. Is there a similar service that can be provided that is at least as likely to produce equivalent therapeutic or diagnostic results?

For those services that meet the criteria described above in the Position Statement, yes. Proton beam therapy for the treatment of prostate cancer is merely one of many different treatments for prostate cancer. Several forms of radiation treatment alone (e.g., intensity modulated radiation therapy (IMRT), brachytherapy) are available for treatment of prostate cancer. Florida Blue, after analysis, has determined that these alternative forms of services are

1.) Similar to proton beam therapy and; 2.) Proton beam therapy has not been documented to have equivalent or better outcomes with regard to the treatment of prostate cancer than such alternative services.

With regard to prostate cancer, there is limited published clinical evidence of proton beam demonstrating clinical equivalence or benefit over conventional forms of radiation therapy (e.g. IMRT, brachytherapy) or surgical treatments for prostate cancer. There is a need for more well-designed registries and studies with sizable comparator cohorts for data collection. As a result there is no clinical documentation demonstrating the safety, benefits, and health outcomes compared to other conventional forms of radiation therapy or, more generally, other forms of treatment for prostate cancer.

Proton Beam Therapy Research Summary

Based upon the above analysis [and research summary], other forms of radiation treatment are clinically equivalent at treating prostate cancer to Proton Beam therapy and, at this time, proton beam therapy is not documented to have superior clinical outcomes.

B. Are the alternative services less costly?

Yes, the other similar alternative forms of treatment are generally less costly than proton beam therapy for the treatment of prostate cancer. In particular, utilizing 2012 Florida Blue claims data, it was determined that the average cost of a treatment episode for of all Florida Blue members (commercial) treated for cancer with proton beam therapy was $56,000. The average cost of a treatment episode for of all Florida Blue members (commercial) treated for cancer with IMRT was $34,000 (a $22,000 or approximately a 40% difference). It should be noted that 80% of PBT treated members had prostate cancer.

As a result, proton beam therapy for the treatment of prostate cancer is considered not medically necessary for policies with definitions of Medical Necessity that include the comparative effectiveness analysis criteria.

For required documentation, refer to the REIMBURSEMENT INFORMATION section of this guideline.

BILLING/CODING INFORMATION:

CPT Coding:

77520

Proton beam delivery; simple, without compensation

77522

Proton beam delivery; simple with compensation

77523

Proton beam delivery; intermediate

77525

Proton beam delivery; complex

HCPCS Coding:

S8030

Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

C41.2

Malignant neoplasm of vertebral column

C41.4

Malignant neoplasm of pelvic bones, sacrum and coccyx

C41.9

Malignant neoplasm of bone and articular cartilage, unspecified

C69.30

Malignant neoplasm of unspecified choroid

C69.40

Malignant neoplasm of unspecified ciliary body

C69.90

Malignant neoplasm of unspecified site of unspecified eye

C71.0 – C71.9

Malignant neoplasm of brain

C72.0-C72.1

Malignant neoplasm of spinal cord, cranial nerves and other parts of central nervous system

C72.20 – C72.22

Malignant neoplasm of olfactory nerve

C72.30-C72.32

Malignant neoplasm of optic nerve

C72.40-C72.42

Malignant neoplasm of acoustic nerve

C72.50-C72.59

Malignant neoplasm of unspecified cranial nerve

C72.9

Malignant neoplasm of central nervous system, unspecified

C79.31

Secondary malignant neoplasm of brain

C79.49

Secondary malignant neoplasm of other parts of nervous system

D09.8

Carcinoma in situ of other specified sites

D33.0 – D33.9

Benign neoplasm of brain and other parts of central nervous system

D42.0 – D42.9

Neoplasm of uncertain behavior of meninges

D43.0 – D43.9

Neoplasm of uncertain behavior of brain and central nervous system

D49.6

Neoplasm of unspecified behavior of brain

Q28.2

Arteriovenous malformation of cerebral vessels

Q28.3

Other malformations of cerebral vessels

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for proton beam therapy.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

Required Documentation

The medical record may be requested as part of the review process.

The primary treating physician MUST submit the following information for the member:

PROGRAM EXCEPTIONS:

Note: Coverage for proton beam therapy performed and billed in an outpatient or office location will be handled through the Radiation Oncology program for select products. AIM Specialty Health will determine coverage for proton beam therapy for select products. Refer to member's contract benefits.

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline review date: Proton Beam Radiotherapy, (L33937) located at fcso.com.

DEFINITIONS:

Craniopharyngioma: A tumor arising from cell rests derived from the hypophysial stalk or Rathke’s pouch, frequently associated with increased intracranial press, and showing calcium deposits in the capsule or in the tumor proper. Also called craniopharyngeal duct tumor, Rathke’s or Rathke’s pouch tumor, suprasellar cyst, and pituitary adamantinoma or ameloblastoma.

Glioblastoma: A general term for malignant forms of astrocytoma. It occurs in the brain stem of children and occasionally in the spinal cord of an adult or child.

IRB (Institutional Review Board): a group of individuals (e.g., scientists, physicians, clergy, patient advocates) that reviews and approves the detailed plan for clinical trials.

Malignant: Cancerous. Malignant tumors can invade and destroy nearby tissue and spread to other parts of the body.

Medulloblastoma: A malignant, highly radiosensitive cerebellar tumor composed of undifferentiated neuroglial cells and usually considered a type of primitive neuroectodermal tumor. Most medulloblastomas occur in children and arise in or adjacent to the roof of the fourth ventricle.

Tumor: A new growth of tissue in which the multiplication of cells is uncontrolled and progressive; also called neoplasm (benign or malignant).

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report proton beam:

Charged Particle Radiation Therapy
Charged Particle Radiotherapy
Hadron therapy
Helium Ion Radiation Therapy
Particle Beam Therapy
Proton Beam Radiation Therapy
Proton Beam Radiotherapy

REFERENCES:

  1. ASTRO Proton Beam Therapy (PBT) Model Policy, 2014.
  2. ACR–ASTRO Practice Guideline for the Performance of Proton Beam Radiation Therapy, Amended 2014.
  3. AIM Specialty Health Clinical Appropriateness Guidelines: Radiation Oncology Proton Beam Radiation Therapy (PBRT), 01/01/16.
  4. Al-Shahi R, Warlow CP. Interventions for Treating Brain Arteriovenous Malformations in Adults. The Cochrane Database of Systematic Review 2006, Issue 1. Art. No.: CD003436.pub2. DOI: 10.1002/14651858. CD003436.pub2.
  5. American Academy of Pediatrics Section Statement: Guidelines for the Pediatric Cancer Center and Role of Such Centers in Diagnosis and Treatment. Pediatrics 1997 (current as of 05/19/06); 99(1): 139-141.
  6. Archamabeau JO, Slater JD, Slater JM et al. Role For Proton Beam Irradiation in Treatment of Pediatric CNS Malignancies. International Journal of Radiation Oncology Biology Physics 1992; 22(2): 287-294.
  7. Arimoto T, Kitagawa T, Tsujii H et al. High-Energy Proton Beam Radiation Therapy for Gynecologic Malignancies. Cancer July 1991; 68 (1): 79-83.
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  10. American Society of Radiation Oncology (ASTRO) Proton Beam Therapy Model Policy, 05/20/14.
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  15. Blue Shield Association Technology Assessment-Charged Particle (Proton or Helium Ion) Irradiation for Uveal Melanoma and for Chordoma or Chondrosarcoma of the Skull Base or Cervical Spine, Vol. 11 No.1, 06/96.
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  47. Kaeashima M, Furuse J, Nishio T et al. Phase II Study of Radiotherapy Employing Proton Beam for Hepatocellular Carcinoma. Journal of Clinical Oncology 2005; 23(9): 1839-1846.
  48. Kil WJ, Nichols RC, Hoppe BS et al. Hypofractionated passively scattered proton radiotherapy for low- and intermediate-risk prostate cancer is not associated with post-treatment testosterone suppression. Acta Oncologica 2013; 52(3): 492-497.
  49. Kodjikian L, Roy P, Rouberol F et al. Survival After Proton-Beam Irradiation of Uveal Melanomas. American Journal of Ophthalmology 2004; 137(6): 1002-1010.
  50. Konski A, Speier W, Hanlon A et al. I proton beam therapy cost effective in the treatment of adenocarcinoma of the prostate? Journal of Clinical Oncology 2007; 25(24): 3603-3608.
  51. Koyama S, Tsujii H. Proton Beam Therapy with High-Dose Irradiation for Superficial and Advanced Esophageal Carcinomas. Clinical Cancer Research 2003; 9: 3571-3577.
  52. Mak AC, Morrison WH, Garden AS et al. Base-Of-Tongue Carcinoma: Treatment Results Using Concomitant Boost Radiotherapy. International Journal of Radiation Oncology, Biology, Physics 1995; 33(2): 289-296.
  53. Matsuzaki Y, Osuga T, Saito Y et al. A New, Effective, and Safe Therapeutic Option Using Proton Irradiation for Hepatocellular Carcinoma. Gastroenterology 1994; 106: 1032-1041.
  54. McAllister B, Archambeau JO, Nguyen MC et al. Proton Therapy for Pediatric Cranial Tumors: Preliminary Report on Treatment and Disease-Related Morbidities. International Journal of Radiation Oncology Biology Physics 1997; 39(2): 455-460.
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the Florida Blue Medical Policy & Coverage Committee on 12/01/16.

GUIDELINE UPDATE INFORMATION:

06/15/02

Reviewed; proton beam delivery information separated from Radiation Treatment Delivery and Radiation Treatment Management MCG; added one additional diagnosis code.

07/15/03

Annual review. Added rationale to support investigational statement.

01/15/04

Added S8030, and updated references.

09/15/04

Scheduled review, and updated references.

06/15/05

Scheduled review. Revised when services are covered. Added localized prostate cancer to the when services are covered. Revised when services are not covered. Added ICD-9 diagnosis 185 (malignant neoplasm of the prostate). Added charge particle radiation therapy and helium ion radiation therapy to the other section, and updated references.

04/15/07

Deleted “Radiation” from MCG title. Revised WHEN SERVICES ARE COVERED; expanded covered indications to include: intraocular melanomas, benign or malignant conditions involving the base of the skull or axial skeleton, including but not limited to chordomas and chondrosarcomas, benign or malignant central nervous system tumors, including primary and variant forms of medulloblastoma, astrocytoma, glioblastoma, arteriovenous malformations, acoustic neuroma, craniopharyngioma, benign and atypical meningomas and pineal gland tumors, solid tumors in children, malignant lesions of the head and neck, malignant lesions of the para nasal sinus, and other accessory sinuses, malignant advanced state-non-metastatic tumors of the bladder, advanced pelvic tumors, malignant lesions of the cervix, left breast tumors, adrenal tumors, skin cancer with perineural/cranial nerve invasion, unresectable retroperitoneal sarcoma, unresectable extremity sarcoma, lung cancer, upper abdominal cancer, peridiaphragmatic cancer, malignant lesions of liver, malignant lesions of biliary tract, malignant lesions of anal canal, and malignant lesions of rectum. Expanded ICD-9 diagnoses for proton beam therapy to include: 141.0, 142.0, 142.1, 142.2, 143.0, 143.1, 144.0 – 144.9, 145.0 – 145.9, 146.0 – 146.9, 147.0 – 147.9, 148.0 – 148.9, 149.0, 149.1, 154.0 – 154.8, 155.0 – 155.2, 157.0 – 157.9, 158.0, 160.0 – 160.9, 161.0 – 161.9, 162.0 – 162.9, 164.0, 164.1, 164.2, 164.3, 170.0 – 170.9, 171.0 – 171.9, 173.0 – 173.9, 174.0 – 174.6, 180.0 – 180.8, 183.0, 184.0, 188.0 – 188.9, 189.0, 190.0 – 190.9, 191.0 – 191.9, 192.0, 192.1, 192.2, 192.3, 192.8, 193, 194.1, 194.3, 194.4, 195.1, 195.2, 195.3, 197.0, 197.7, 198.3, 225.0-225.8, 227.3, 227.4, 237.0, 237.1, 237.5, 237.6, and 747.81. Revised code descriptor for 198.5. Added guideline specific definitions. Added Charged Particle Radiotherapy and Proton Beam Radiotherapy to OTHER section, and updated references.

06/15/07

Reformatted guideline.

04/15/08

Scheduled review. Revised experimental or investigational statement, and updated references.

04/15/09

Scheduled review. No change in position statements, and updated references.

08/15/10

Revised position statement, deleted malignant advanced state, non-metastatic tumors of the bladder, advanced pelvic tumors, malignant lesions of the cervix, pancreatic tumors, adrenal tumors, skin cancer with perineural/cranial nerve invasion, upper abdominal cancer, malignant lesions of: biliary tract, anal canal, and rectum. Deleted ICD-9 diagnoses codes: 141.0, 142.0, 142.1, 142.2, 143.0, 143.1, 144.0 – 144.9, 145.0 – 145.9, 146.0 – 146.9, 147.0 – 147.9, 148.0 – 148.9, 149.0, 149.1, 154.0 – 154.8, 157.0 – 157.9, 164.0, 164.1, 164.2, 164.3, 171.0 – 171.9, 173.0 – 173.9, 180.0 – 180.8, 183.0, 184.0, 188.0 – 188.9, 189.0, 193, 194.1, 195.1, 195.2, and, 195.3. Added program exception for Medicare Advantage products; covered indications and ICD-9 codes that support medical necessity. Updated references.

02/01/11

Revision; related ICD-10 codes added.

10/15/11

Annual review; maintain position statements. Added uveal tract (iris, ciliary body, choroid) to intraocular melanomas). Added definition for axial skeleton. Updated references.

05/01/16

Revision; updated description, added medical necessity criteria for: benign or malignant conditions involving the base of the skull or axial skeleton, left breast tumors, lung cancer, malignant lesions of liver, peri-diaphragmatic cancer, unresectable extremity sarcoma, unresectable retroperitoneal sarcoma, and upper abdominal cancer; added medical necessity position statement and criteria for prostate cancer, added comparative effectiveness analysis statement and flowchart; added comparative effective analysis statement for proton beam therapy for the treatment of prostate cancer, updated ICD-10 codes; updated program exception; added LOINC codes; updated references.

08/15/16

Updated program exceptions.

12/15/16

Revision; updated references.

Date Printed: August 21, 2017: 07:39 PM