Humana medical policy · HUM-PBRT-DEMO
Proton Beam Radiation Therapy
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Proton Beam Radiation Therapy
Humana Medical Coverage Policy · Demo snapshot (placeholder criteria, not verified against PolicyBot) · Effective date: January 1, 2026 · Applies to Medicare Advantage and commercial products
I. General requirements
Proton beam radiation therapy (PBRT) may be considered medically necessary when the member meets the general requirements below and the disease-specific criteria in Section II.
A. Member status
1. The treating radiation oncologist has recommended PBRT in a documented consultation.
2. The member has an estimated life expectancy of at least 10 years and an ECOG performance status of 0 or 1.C-4
II. Disease-specific criteria
A. Localized prostate cancer (definitive treatment)
1. Adenocarcinoma of the prostate is confirmed by histopathology from a core needle biopsy.C-1
2. The NCCN risk group is documented, including the Gleason grade group and the number or percentage of positive biopsy cores.C-2
3. A pretreatment PSA drawn within 90 days and the clinical T stage are documented.C-3
4. The member has been evaluated by a urologist, and alternatives including radical prostatectomy and photon-based radiation were discussed.C-5
5. The member is enrolled in an IRB-approved clinical trial or a prospective outcomes registry.C-6
6. For high-risk or very-high-risk disease, pelvic nodal staging by PSMA PET or CT and bone scan is documented.C-12
B. Prostate cancer after prostatectomy
1. For postoperative or salvage treatment after prostatectomy, the surgical pathology and post-operative PSA values are documented.C-11
C. Re-irradiation
1. For re-irradiation of the pelvis, the dose, dates and fields of the prior course are documented.C-13
III. Dosimetric documentation
A. Prescription
1. The prescribed total dose, dose per fraction and number of fractions are documented.C-7
B. Comparative planning and normal tissue sparing
1. A comparative IMRT plan on the same target volumes is submitted, with dose-volume histogram values for the rectum and bladder for both plans.C-8
2. Placement of a rectal spacer is documented, or the reason a spacer was not placed is stated.C-9
IV. Documentation
A. A letter of medical necessity signed by the treating radiation oncologist accompanies the request.C-10
V. Not medically necessary
PBRT is not medically necessary when the comparative plan shows no meaningful reduction in dose to the rectum or bladder relative to IMRT, or when the member does not meet Section I.