Aetna medical policy · AET-PBRT-DEMO
Proton Beam Radiotherapy
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Proton Beam Radiotherapy
Aetna Clinical Policy Bulletin · Demo snapshot (placeholder criteria, not verified against PolicyBot) · Effective date: March 1, 2026 · Applies to Aetna commercial medical plans
I. General criteria
Aetna considers proton beam radiotherapy medically necessary for head and neck cancers when all general criteria are met and either Section II or Section III applies.
A. Diagnosis and member status
1. The malignancy, or its recurrence, is confirmed by histopathology.C-1
2. Staging or restaging imaging performed within 60 days documents the extent of disease and the absence of distant metastases.C-2
3. The member has a Karnofsky performance status of 70 or higher.C-3
B. Multidisciplinary review
1. A multidisciplinary tumor board has reviewed the case and recommends radiotherapy.C-4
C. Treatment plan
1. The prescribed dose and fractionation for the proposed course are documented.C-5
2. A comparative photon (IMRT) plan demonstrates a clinically meaningful dosimetric advantage for proton therapy.C-6
II. Newly diagnosed head and neck cancer
A. Definitive treatment
1. For a newly diagnosed oropharyngeal cancer, HPV or p16 status is documented.C-7
2. For a first course of radiation to the head and neck, the comparison reports mean dose to the parotid glands and oral cavity for each plan.C-8
III. Re-irradiation of recurrent or second primary head and neck cancer
A. Prior course and candidacy
1. The dates, total dose, fractionation and treated site of the prior radiation course are documented.C-9
2. At least 6 months have elapsed since completion of the prior radiation course.C-10
3. A head and neck surgeon has evaluated the member, and salvage surgery is not feasible or has been declined.C-11
B. Cumulative dose
1. Cumulative dose to the spinal cord and brainstem from the prior and proposed courses is reported from a composite (summed) plan.C-12
IV. Documentation
A. A letter of medical necessity signed by the treating radiation oncologist is submitted.C-13
V. Experimental and investigational
Proton beam radiotherapy is considered experimental and investigational when the criteria above are not met.