Blue Cross and Blue Shield of Texas medical policy · BCBSTX-RAD-DEMO
Proton Beam Therapy
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Proton Beam Therapy
Blue Cross and Blue Shield of Texas Medical Policy · Demo snapshot (placeholder criteria, not verified against PolicyBot) · Effective date: April 1, 2026
I. General criteria
1. The diagnosis is established by pathology.C-1
2. The stage and extent of disease are documented by imaging.C-2
3. Performance status (ECOG, KPS or Lansky) is documented.C-3
4. The treatment plan has been discussed at a multidisciplinary tumor board.C-4
II. Dosimetric justification
1. A comparative photon plan shows a clinically relevant reduction in dose to critical structures.C-5
III. Site-specific criteria
A. Breast
1. For breast cancer, mean heart dose and ipsilateral lung V20 are reported for both plans.C-6
B. Pediatric
1. For members under 21, the treatment plan includes the daily anesthesia or sedation plan.C-7
C. Re-irradiation
1. For re-irradiation, the prior radiation summary with dose and dates is included.C-8
IV. Documentation
1. A letter of medical necessity signed by the treating physician is included.C-9
Gold-card providers meeting the plan's approval-rate threshold may receive automated approval for requests that include items I.1 through IV.1.