Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer of the base of the tongue. 
Treatment: Proton beam therapy and associated treatment support codes. 

The insurer denied coverage for proton beam therapy and associated treatment support codes. 

The denial is overturned. 

This is a male with squamous cancer of base of tongue. Proton beam therapy (PBT) is being requested for definitive concurrent chemoradiation treatment on a National Institute of health (NIH) approved registry trial. 

Compared to photon beam radiation therapy (RT), Proton beam RT can achieve significantly sharper dose gradient due to its Bragg peak patterns of energy release and thus can deliver therapeutic high dose to target with significantly better dose conformity and sparing of adjacent normal tissues. 

Proton beam therapy (PBT) has dosimetric advantages that allow it to deposit high radiation doses within the target, while largely sparing surrounding structures. Because of this advantage, PBT has the potential to improve both tumor control and radiation induced normal tissue toxicity. 

Per 2017 ASTRO (American Society for Radiation Oncology) model policy for proton beam RT states that, "while PBT is not a new technology, there is a need for continued clinical evidence development and comparative effectiveness analyses for the appropriate use of PBT for various disease sites. 

The requesting facility has physician training/experience, and available physics support. The patient is a good candidate for the requested procedures, the procedures are the best available treatment for the patient at this time and the adverse risks are not increased over standard treatment/services. The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 
 
Thus, the requested proton beam therapy and associated treatment support codes are consistent with the 2017 ASTRO model policy for proton beam therapy and NCCN guidelines (National Comprehensive Cancer Network) on head and neck cancer 2022, and therefore, should be approved. 

The carrier's denial of procedure codes procedure codes 77263, therapeutic radiology treatment planning; complex; 77301, intensity modulated radiotherapy plan, including dose volume histograms for target and critical structure partial tolerance specifications; 77293, respiratory motion stimulation; 77336 (x7), continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose
delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy, 77300 (x10); basic radiation dosimetry calculation, central axis depth dose calculation TDF (Time Dose Fractionation Factor), NSD (Nominal Standard Dose), gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician; 77427 (x7), radiation treatment management, 5 treatments; 77332 (x10), treatment devices, design and construction; simple (simple block); 77333 (x10), treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus); 77334 (x10), treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds, or casts); 77370, special medical radiation physics consultation; 77470, special treatment procedure; 77331, special dosimetry only when prescribed by the treating physician, 77520 (x35) Proton treatment delivery; simple, without compensation, 77523 (x35) proton treatment delivery; intermediate, 77525 (x35) proton treatment delivery, complex; 77014 (x35) computed tomography guidance for placement of radiation therapy fields, G6002 (x35) stereoscopic x-ray guidance for localization of target volume for delivery of radiation therapy and 77387 (x35) guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed should be overturned.