Blue Cross & Blue Shield of MississippiAll Plans · Coverage · Medical Policy · Radiation Oncology, OncologyMedium impact
Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Charged-particle irradiation with proton or helium ion beams may be considered medically necessary for primary therapy of uveal tract melanoma meeting the listed size and metastasis criteria, for postoperative therapy after biopsy or partial resection of skull-base chordoma, low-grade chondrosarcoma or cervical spine lesions with residual localized tumor, and for pediatric central nervous system tumors. It may also be considered medically necessary where photon-based radiotherapy cannot meet normal tissue dose-volume constraints, including curative treatment of primary or benign solid pediatric non-CNS tumors such as Ewing sarcoma, nonmetastatic primary non-small cell lung cancer, and head and neck cancers. Clinically localized prostate cancer and non-curative treatment of these pediatric tumors and non-small cell lung cancer are considered investigational.
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01Check current applicability before acting on this policy.
02Billing team: for the photon dose-constraint indications, attach clinical documentation based on dosimetry plans showing that conventional or advanced photon-based radiotherapy (IMRT, VMAT, SRS or SBRT) would exceed tolerance doses to the structures at risk.
03For individuals with NF-1 or retinoblastoma, attach clinical documentation of the condition to show increased risk from radiation exposure.
04BCBSMS makes no payment for services not documented to be Medically Necessary.
05Clinically localized prostate cancer is considered investigational under this policy.
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