S8030, Scleral application of tantalum ring(s) for localization of lesions for proton
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical documentation of prior irradiation to the same or adjacent area and treatment planning showing the need to sculpt dose to avoid exceeding cumulative normal-tissue tolerance.
- Proof of enrollment and compliance with an IRB‑approved clinical trial or a multi‑institutional patient registry that meets Medicare CED requirements (protocol/registry documentation).
- Clinical documentation of tumor anatomic location and extent (e.g., periocular location, orbit/skull base/cavernous sinus invasion, intracranial extension).
- Pathology, imaging, or operative reports documenting extensive perineural invasion when claimed.
Key Coverage Criteria
- Proton beam therapy (PBT) for tumors that are inoperable or when precise dose delivery is needed to minimize radiation to surrounding healthy tissue or critical structures.
- Ocular tumors, including intraocular melanomas.
- Primary spine or spinal cord tumors or metastatic spine/spinal cord tumors when organ-at-risk (OAR) tolerance may be exceeded with photon treatments.
- Tumors at or approaching the base of the skull, including chordoma and chondrosarcoma.
- Hepatocellular carcinoma and intra-hepatic biliary cancers.
- Primary or benign solid tumors or other hematologic malignancies in members/enrollees aged ≤21 years.
7 Active Policies
AMBETTER-CP.MP.70, Proton and Neutron Beam Therapies
CARELON-proton-beam-therapy-2025-03-23, Proton Beam Therapy
CARELON-radiation-therapy-excludes-proton-2026-04-04, Radiation Therapy Excludes Proton
EVICORE-HPLAN-CIGNA-1815296EE67F, Cigna Comprehensive Code List - Effective 03/07/2026
Related Codes
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