Proton Beam Therapy

Proton Beam Therapy (PBT) is covered when it provides a demonstrable dosimetric advantage over photon radiotherapy—such as sparing critical structures, reducing hotspots in large volumes, avoiding excess integral dose, or enabling safe re-irradiation. Coverage is commonly supported for specified Group 1 disease sites (ocular, skull base, spine, unresectable CNS tumors, pediatric curative tumors, select liver and head/neck cancers, retroperitoneal sarcoma, etc.), while Group 2 sites may be covered if provided by experienced centers with publication history; documentation of comparative DVHs, physician justification, simulation/contouring, dosimetric planning, and patient-specific verification is required.

"PBT is covered when sparing surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and PBT provides added clinical benefit for the patient."