Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer of base of 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. 

According to the medical records, the patient is a male with a history of a malignant mass on the right side of the neck, obstructive sleep apnea (OSA), thoracic aortic aneurysm (AAA), hypertension, and dyslipidemia. He presented to the Radiation Oncologist's office for a follow up for malignant neoplasm. The physician recommended proton beam therapy (PBT) to treat oropharyngeal cancer. The oncologist recommended proton beam therapy (PBT) to treat oropharyngeal cancer. 

Charged-particle beams consisting of protons or helium ions are a type of particulate radiation therapy that contrast with conventional electromagnetic (i.e., photon) radiation therapy due to the unique properties of minimal scatter as the particulate beams pass through the tissue, and deposition of the ionizing energy at a precise depth (i.e., the Bragg Peak). Thus, radiation exposure to surrounding normal tissues is minimized. 

"Radiotherapy is a common treatment modality in the management of head and neck malignancies. In select clinical scenarios of well-lateralized tumors, radiotherapy can be delivered to the primary tumor or tumor bed and the ipsilateral nodal regions, while intentional irradiation of the contralateral neck is omitted. Proton beam therapy is an advanced radiotherapy modality that allows for the elimination of exit-dose through nontarget tissues such as the oral cavity. This dosimetric advantage is apt for unilateral treatments." (Press, R. H. et al. 2021). 

"Proton beam therapy is an effective and well-tolerated treatment modality of skull base paragangliomas, with documented functional benefit. A longer follow-up is planned in order to assess local control and long-term toxicities." (Cao, K. I. et al. 2018). 
    
The carrier's denial of 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.