UnitedHealthcare medical policy · 2026T0123EE
Proton Beam Radiation Therapy
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Proton Beam Radiation Therapy
Policy number: 2026T0123EE · Effective date: July 1, 2026 · UnitedHealthcare Commercial Medical Policy
I. General requirements
Proton beam radiation therapy (PBT) is proven and medically necessary when all of the following general requirements are met, in addition to the site-specific criteria in Section II.
A. Diagnosis and patient status
1. The diagnosis is confirmed by histopathology from a biopsy or resection specimen.C-1
2. The clinical stage (AJCC TNM) is documented from imaging performed within 90 days.C-3
3. The patient has an ECOG performance status of 0 to 2.C-5
B. Treatment planning review
1. The treatment plan has been reviewed by a multidisciplinary tumor board.C-6
II. Site-specific criteria
A. Covered indications
PBT is covered for ocular tumors, skull base tumors, primary spinal tumors, pediatric malignancies, and head and neck cancers meeting Section II.B.
B. Head and neck cancers
1. For oropharyngeal primaries, HPV or p16 status is documented.C-2
2. Radiation therapy is delivered with curative intent as definitive treatment.C-4
C. Re-irradiation
1. For re-irradiation, the dates and dose of the prior course and the interval since its completion are documented.C-12
III. Dosimetric documentation
A. Prescription
1. The prescribed total dose and number of fractions are documented.C-7
B. Comparative planning
1. A comparative IMRT plan for the same target volumes accompanies the request.C-8
2. The comparison demonstrates a clinically meaningful reduction in mean dose to the ipsilateral parotid gland, reported as a numeric value for each plan.C-9
C. Supportive care
1. A dental evaluation has been completed prior to the start of radiation therapy.C-10
IV. Attestation
A. The treating radiation oncologist attests, by signature, that proton therapy is medically necessary for this patient.C-11
V. Not medically necessary
PBT is not medically necessary for indications not listed above, or when the comparative plan does not show a dosimetric advantage over IMRT.