77520
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The patient's medical record must contain documentation that fully supports medical necessity for services included in the related LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Include a treatment prescription that defines treatment goals and specific dose-volume parameters for the target and nearby critical structures, and details of beam delivery such as method of beam modulation, field arrangement, and expected positional and range uncertainties.
- Include a physician-signed treatment plan that meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) accounting for expected uncertainties.
- Describe the target setup verification methodology, including patient positioning, immobilization, and use of image guidance.
Key Coverage Criteria
- Proton beam therapy is covered when the service meets the medical necessity criteria specified in the related Local Coverage Determination (LCD) and those criteria are documented in the medical record.
- Proton beam radiotherapy is covered for solid tumors in pediatric patients up to age 18.
- Proton beam radiotherapy is covered for benign or malignant conditions involving the base of the skull or axial skeleton that are not suitable for IMRT or 3-dimensional conformal therapy, including but not limited to chordomas and chondrosarcomas.
- Proton beam radiotherapy is covered for benign or malignant central nervous system tumors, including primary and variant medulloblastoma, astrocytoma, glioblastoma, arteriovenous malformation, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, and pineal gland tumors.
- Proton beam radiotherapy is covered for intraocular melanoma.
- Proton beam radiotherapy may be covered for Group #2 conditions (listed below) only when the following combined conditions are met: (A) at least one of: dose constraints to normal tissues limit safe total dose with other methods; higher doses than attainable with other methods may improve control; or the higher precision of proton therapy is clinically necessary; AND (B) either the treatment intent is curative for a primary lesion or, for a metastatic lesion, there is documented expectation of l [...]
20 Active Policies
L35075 — Proton Beam Therapy
J06
A56827 — Billing and Coding: Proton Beam Therapy
J06
CGS-L36658 — Proton Beam Therapy
J18 MAC Part B
FIRST_COAST-L33937 — Proton Beam Radiotherapy
J9 MAC Part B
NGS-L35075 — Proton Beam Therapy
Related Codes
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