77525
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
- All documentation must be maintained in the patient medical record, be legible, include patient identification (complete name, dates of service), and be available to the contractor upon request.
- Medical record must identify the physician or non-physician practitioner responsible for and providing the patient's care.
- Submitted medical record must support the use of the selected diagnosis code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- Documentation must include the planned course of therapy, type and delivery of treatment, level of clinical management involved, ongoing documentation of any changes in course of treatment, and DHV as noted in the covered indications section.
Key Coverage Criteria
- Proton beam therapy is covered when the medical record documents that the service is reasonable and necessary per LCD L36658 and supports the selected diagnosis codes and planned course of therapy.
- 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.
- Coverage for proton beam radiotherapy is determined by Local Coverage Determination L33937 and is allowed only when the service meets the LCD's reasonable and necessary requirements.
- 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.
18 Active Policies
L35075 — Proton Beam Therapy
J06
A56827 — Billing and Coding: Proton Beam Therapy
J06
A57669 — Billing and Coding: Proton Beam Radiotherapy
L36658 — Proton Beam Therapy
L33937 — Proton Beam Radiotherapy
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.