Charged-particle irradiation with proton or helium ion beams may be considered medically necessary for treatment in the following clinical situations:
primary therapy for melanoma of the uveal tract (iris, choroid, or ciliary body), with no evidence of metastasis or extrascleral extension, and with tumors up to 24 mm in largest diameter and 14 mm in height;
postoperative therapy (with or without conventional high-energy x-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II) chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine. Patients eligible for this treatment have residual localized tumor without evidence of metastasis;
pediatric central nervous system tumors.
Charged-particle irradiation with proton or helium ion beams may be considered medically necessary where treatment planning with conventional or advanced photon-based radiotherapy cannot meet dose-volume constraints for normal tissue radiation tolerance (see Policy Guidelines section) in the following clinical situations:
in the curative treatment of primary or benign solid pediatric non-central nervous system tumors, including Ewing sarcoma;
in the curative treatment of nonmetastatic primary non-small cell lung cancer;
head and neck cancers.
Other applications of charged-particle irradiation with proton or helium ion beams may be considered investigational. This includes, but may not be limited to:
clinically localized prostate cancer;
non-curative treatment of primary or benign solid pediatric non-central nervous system tumors, including Ewing sarcoma;
non-curative treatment of non-small cell lung cancer.
