NAPT Updates Insurance Model Policy for Proton Therapy

Roxanne Nelson, RN

April 02, 2015

The National Association for Proton Therapy (NAPT) has updated its model policy for insurance coverage that clarifies the most appropriate clinical indications for proton-beam therapy.

The model has been endorsed by the Particle Therapy Cooperative Group-North America and the Alliance of Dedicated Cancer Centers. It identifies the conditions, including various types of cancer, for which peer-reviewed scientific evidence and clinical experience supports the use of proton therapy.

The NAPT has expressed hope that "payers will accept and adopt this model coverage policy as their own and use it as a guide for reimbursing proton-beam therapy procedures."

The model, based on local Medicare and Blue Cross Blue Shield coverage policies, was developed to streamline the process by which payers reimburse for the procedure.

The American Society for Radiation Oncology released its own policy on reimbursement for proton-beam therapy last year.

Proton therapy is an alternative to standard radiotherapy for the treatment of cancer, but it is somewhat controversial because there is little evidence to support the claim that toxicity is lower than with standard radiation, and it is substantially more expensive.

New Journal Articles Added

The NAPT policy was originally released in March 2014, but was updated to include 15 peer-reviewed journal articles published in the past 12 months that had "significant and compelling" findings, according to the NAPT.

These additional studies assessed the use of proton-beam therapy for a variety of cancer types, including head and neck tumors, non-small cell lung cancer, esophageal cancer, locally advanced breast cancer, and malignancies in pediatric patients.

Emerging evidence in head and neck cancer patients suggests that even though proton therapy is initially more expensive, "by the end of treatment, the episodic cost of care is similar to standard radiation, as patients experience less toxicity with protons and, as a result, require fewer emergency department visits, hospitalizations, and feeding tubes," Steven J. Frank, MD, medical director at the M.D. Anderson Proton Therapy Center in Houston, said in a statement.

"This makes proton therapy a cost-effective form of radiation therapy, and we believe that once payers understand these benefits, access to this effective treatment against cancer for many patients will increase," Dr Frank explained.

Indications

According to the updated NAPT policy, proton-beam therapy should be considered medically reasonable and necessary for the following conditions:

  • Benign or malignant central nervous system tumors, including but not limited to primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations

  • Intraocular melanomas

  • Pituitary neoplasms

  • Benign or malignant conditions of the base of the skull or axial skeleton, including but not limited to chordomas and chondrosarcomas

  • Malignant lesions of the head and neck

  • Lung cancers, especially non-small cell lung cancer

  • Unresectable retroperitoneal sarcoma

  • Solid tumors in children up to 18 years of age

  • Gastrointestinal tract tumors, urinary tract tumors, and tumors of the female pelvic organs

  • Prostate cancer

In addition, proton-beam therapy is indicated when there is documented clinical rationale that control rates might be improved with doses generally thought to be above the level attainable with other radiation methods, and when high levels of precision are clinically necessary.

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