ASTRO Releases Proton Therapy Insurance Coverage Policy

The premier radiation oncology society in the world, the American Society for Radiation Oncologists (ASTRO), has issued a new Model Policy for proton beam therapy (PBT) that details which cancer diagnoses meet ASTRO’s evidence-based standards and should be covered by private insurers and Medicare.  This is a very significant and welcome development that will help us gain insurance coverage for patients that require proton therapy.

All patients at the Provision Center for Proton Therapy are registered on a multi-institutional registry.  ASTRO stated in their new policy “All indications are suitable for Coverage with Evidence Development (CED).  Proton therapy patients should be covered by the insurance carrier as long as the patient is enrolled in either an IRB-approved clinical trial or in a multi-institutional patient registry.  At this time, no indications are deemed inappropriate for CED.”

Developed by leading radiation oncologists and medical physicists, including significant input from expert representatives in proton therapy, this Model Policy supports PBT coverage for appropriate patients and identifies areas where coverage with evidence development and further research are needed.  ASTRO Model Policies are developed to communicate what ASTRO believes are correct insurance coverage policies for radiation oncology.

ASTRO went on to state:  PBT is neither a new nor an experimental technology for treating cancer with radiation. It utilizes proton radiation particles to deliver highly conformal radiation therapy to a specific tumor target area while giving a much lower dose to the normal tissues in the proton beam’s path of entry and exit. PBT’s reduced radiation dose to healthy tissues is attractive because it can reduce side effects for patients, which potentially increases their quality of life.

“Proton beam therapy (PBT) is demonstrating promise in our continuing efforts to improve survival and cure rates for cancer patients while reducing side effects,” said Colleen A.F. Lawton, MD, FASTRO, chair of ASTRO’s Board of Directors. “As the leading experts in radiation oncology, it is important for ASTRO to provide balanced, evidence-based guidance to payers that ensures access to PBT for cancer patients while being judicious stewards of our nation’s and our patients’ financial resources.”

This Model Policy recommends two coverage groups for PBT: 1) patients with specific diagnoses for which PBT has been proven to be effective; and 2) patients with cancer diagnoses where evidence of effectiveness of PBT is still emerging, and therefore coverage with evidence development is recommended for patients if they are enrolled in clinical trials or a multi-institutional registry to collect data and inform consensus on the role of proton therapy.

ASTRO Model Policies are developed to communicate what ASTRO believes are correct coverage policies for radiation oncology. The ASTRO Model Policies do not serve as clinical guidelines, and they are subject to periodic review and revision. The ASTRO Model Policies may be reproduced and distributed, without modification, for noncommercial purposes. ASTRO has previously issued Model Policies on coverage for brachytherapy, intensity modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS), and they are available online at www.astro.org/Daily-Practice/Reimbursement/Model-Policies/Model-Policies/.

The PBT Model Policy was approved by ASTRO’s Board of Directors on May 20, 2014, and is available online at www.astro.org/.

ASTRO is the premier radiation oncology society in the world, with more than 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists and other health care professionals that specialize in treating patients with radiation therapies. As the leading organization in radiation oncology, the Society is dedicated to improving patient care through professional education and training, support for clinical practice and health policy standards, advancement of science and research, and advocacy.