ASTRO Updates Insurance Coverage Recommendation for Proton Therapy to Treat Cancer


For the first time since 2014, the American Society for Radiation Oncology (ASTRO) updated its recommendations for insurance coverage of proton beam radiation for the treatment of cancer.


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The updated guideline—titles Proton Beam Therapy Model Policy—offers guidance to payers on clinical characteristics that are appropriate for proton beam therapy treatment and should be covered by Medicare, Medicaid, and private insurance. This is the first update to the original policy, issued in 2014.

The new policy outlines two categories of appropriate clinical diagnoses for proton beam therapy. For indications in Group 1, coverage is recommended. Five additions and one modification was made to indications in this group, including:

  • Malignant and benign primary central nervous system (CNS) tumors
  • Advanced and/or unresectable head and neck cancers
  • Cancers of the paranasal sinuses and other accessory sinuses
  • Nonmetastatic retroperitoneal sarcomas
  • Reirradiation cases where cumulative critical structure dose would exceed tolerance dose
  • Hepatocellular cancer (no longer required to be treated in a hypofractionated regimen)

For indications in Group 2, coverage is recommended if additional requirements are met: patients must be enrolled in either an Institutional Research Board (IRB)-approved study or in a multi-institutional registry adhering to Medicare requirements for Coverage with Evidence Development. Group 2 indications include:

  • Non-T4 and resectable head and neck cancers (previously all head and neck malignancies*)
  • Nonmetastatic prostate cancer (previously grouped with genitourinary carcinomas*)
  • Breast cancer*
  • Thoracic malignancies, including nonmetastatic primary lung and esophageal cancers
  • Abdominal malignancies, including nonmetastatic primary pancreatic, biliary and adrenal cancers
  • Pelvic malignancies, including nonmetastatic rectal, anal, bladder and cervical cancers

“This policy update reflects the most current knowledge regarding which patients will benefit from—and therefore should have access to—[proton beam therapy]," said David C Beyer, MD, FASTRO, ASTRO chair, in a press release (July 13, 2017).—Zachary Bessette