Proton or Helium Ion Beam (Charged Particle) Radiation Therapy
DESCRIPTION
Proton or helium ion beam (charged particle) radiation therapy is a type of particulate radiation therapy that differs from conventional electromagnetic and/or photon radiation therapy. The use of protons (or helium ions) is produced by an accelerator (cyclotron, synchrotron, synchrocyclotron, or linear). This type of radiation is unique because it allows for minimal scattering as particulate beams pass through tissue and disposes ionizing energy at precise depths (i.e., the Bragg peak). This results in minimizing tissue damage around the area. This type of therapy requires accurate localization of tumor and precise, reproducible positioning of the individual. During the procedure, the individual must be completely immobilized.
POLICY
The use of proton/helium ion beam (charged particle) radiation therapy for the treatment of cancer is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
The use of proton/helium ion beam (charged particle) radiation therapy for the treatment of macular degeneration is considered investigational.
The use of proton/helium ion beam (charged particle) radiation therapy for the treatment of prostate cancer is considered not medically necessary; the clinical outcomes with this treatment have not been shown to be superior to other approaches (e.g., intensity modulation radiation therapy or conformal radiation therapy) and proton beam therapy is generally more costly than these alternatives.
MEDICAL APPROPRIATENESS
The use of proton/helium ion beam (charged particle) radiation therapy is considered medically appropriate if any of the following criteria are met:
Primary therapy for melanoma of the uveal tract (i. e., iris, choroid, or ciliary body), with no evidence of metastasis or extrascleral extension and with tumors up to 24 mm in largest diameter and 14 mm in height; or
Postoperatively in individuals who have undergone either biopsy or partial resection of the chordoma or low-grade (I or II) chondrosarcoma of the basisphenoid region (skull base) or cervical spine, without metastasis and with localized tumor; and
When all of the following apply:
Conventional treatment modalities have failed to provide adequate tumor control; and
Likelihood of metastasis prior to radiotherapy is small to non-existent; and
Evidence exists that local tumor response depends on the exact dose of radiation delivered; and
Limitations exist for delivery of adequate radiation dose due to proximity of tumor to vital radiosensitive tissue or structures.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Proton or helium ion beam (charged particle) radiation therapy is a specialized procedure only performed in six centers in the United States.
For the treatment of localized prostate cancer, proton beam therapy has not been shown to be superior to conventional radiation therapy at this time. Further randomized controlled studies are needed.
SOURCES
Agency for Healthcare Research and Quality (AHRQ). (2008, February). Comparative effectiveness of the therapies for clinically localized prostate cancer. Comparative effectiveness review no. 13. Retrieved August 18, 2010 from http://effectivehealthcare.ahrq.gov/ehc/products/9/79/2008_0204ProstateCancerExecSum.pdf.
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2010). Charged-particle (proton or helium ion) radiation therapy (8.01.10). Retrieved June 7, 2010 from BlueWeb. (31 articles and/or guidelines reviewed)
ECRI Institute. Health Technology Information Service. Emerging Technology Report. (2007, May). Proton beam radiation therapy (overview). Retrieved September 25, 2007 from ECRI Institute. (32 articles and/or guidelines reviewed)
Hayes Medical Technology Directory. (2006, October; last update search September 2009). Proton beam therapy for prostate cancer. Retrieved June 14, 2010 from www.Hayesinc.com/subscribers. (57 articles and/or guidelines reviewed)
Hayes Medical Technology Directory. (2006, October; last update search September 2009). Proton beam therapy for thoracic and abdominal organs. Retrieved June 14, 2010 from www.Hayesinc.com/subscribers. (47articles and/or guidelines reviewed)
National Comprehensive Cancer Network. (V.I.2010). NCCN clinical practice guidelines in oncologyTM. Prostate cancer. Retrieved August 18, 2010 http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
U. S. Food and Drug Administration. (2000, July). Center for Devices and Radiological Health. Final Decisions Rendered for July 2000. Retrieved January 31, 2003 from http://www.fda.gov/cdrh/510k/sumjul00.html.
ORIGINAL EFFECTIVE DATE: 3/1/2000
MOST RECENT REVIEW DATE: 8/24/2010
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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