Proton Beam Therapy (Re-review)

Coverage Decision: Covered with conditions

Proton beam therapy is a covered benefit for children/adolescents less than 21 years old.

Proton beam therapy is a covered benefit with conditions for individuals 21 years old and older.

Conditions of Coverage:

For individuals 21 years old and older proton beam therapy is a covered benefit with conditions for the following primary cancers:

  • Esophageal
  • Head/ neck
  • Skull-based
  • Hepatocellular carcinoma
  • Brain/ spinal
  • Ocular
  • Other primary cancers where all other treatment options are contraindicated after review by a multidisciplinary tumor board.

Proton beam therapy is not covered for all other conditions.

Background Information

The technology was first reviewed in 2014 and re-reviewed in May 2019 by the State Health Technology Clinical Committee (HTCC). The committee expanded the coverage to include additional cancer types based on the recent evidence reviewed, and finalized the determination in July 2019. Complete information on this HTCC determination is available at: http://www.hca.wa.gov/about-hca/health-technology-assessment/health-technology-reviews.

In adopting this HTCC coverage determination, the Department has concluded that the determination does not conflict with any state statute. Any coverage for investigational treatment would be considered per WAC 296-20-02850.  Any coverage for health technologies that have a FDA Humanitarian Device Exemption status would be considered per RCW 70.14.120 (1) (b).

Implementation of the Coverage Decision

All requests for proton beam therapy require prior authorization. The service may be covered only for care of a condition accepted on or related to the claim.

For billing information, please refer to L&I Fee Schedules and Payment Policies (MARFS).

 

For State Fund Claims

All requests will be reviewed by L&I’s occupational nurse consultants and claim managers.

  • Complete the Preauthorization Form and fax to:(360) 902-4567
  • For additional information contact the claim manager
    • To obtain the claim manager’s phone number call 1-800-831-5227
    • Attending or concurrent care provider log into the Claims & Account Center (CAC)
For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to:http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

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