Cigna Healthcare medical policy · CIGNA-RO-PBT-DEMO
Radiation Oncology: Proton Beam Therapy
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Radiation Oncology: Proton Beam Therapy
Cigna Medical Coverage Policy · Demo snapshot (placeholder criteria, not verified against PolicyBot) · Effective date: February 15, 2026
A. General
1. Histologic confirmation of the malignancy is provided.C-1
2. Staging workup, including cross-sectional imaging, is complete.C-2
3. The individual has an ECOG performance status of 0 to 2.C-3
4. A multidisciplinary recommendation for radiotherapy is documented.C-6
B. Dosimetry
1. A comparative IMRT plan on the same target volumes accompanies the request.C-5
2. For esophageal cancer, mean heart dose and lung V20 are reported for proton and photon plans.C-4
C. Re-irradiation
1. For re-irradiation, cumulative dose to critical structures is reported.C-7
D. Documentation
1. The request includes a signed letter of medical necessity.C-8