Subject:
Neutron Beam Therapy
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Neutron beam therapy is a form of radiotherapy that is used primarily for the treatment of unresectable or recurrent tumors.
Policy:
(NOTE: This policy only applies to adult members. It does not apply to pediatric members.
For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)
- Neutron beam radiotherapy is considered medically necessary for salivary gland cancers that are inoperable, recurrent, or are resected with gross residual disease or positive margins.
- All other indications for neutron beam radiotherapy are considered investigational.
Medicare Coverage:
There is no National Coverage Determination (NCD) or Local Coverage Determination (LCD) for jurisdiction JL for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy for Neutron Beam Radiotherapy in Cancer Treatment.
[RATIONALE: Neutron beam radiotherapy differs from other forms of radiation particle treatment such as protons or electrons as neutrons have no electrical charge. The treatment effects are the results of the neutron mass producing dense radiation energy distributions. This effect is high energy linear transfer (LET) and may offset the negative effects of low oxygen tension in tumors, leading to increased rate of control in hypoxic tumors.
There is limited research, resulting in a lack of substantial information on its clinical effectiveness, although it has been tried in soft tissue sarcoma, prostate cancer, pancreas, colon, and lung cancers amongst others. The lack of data and comparative trials limits its designation to EIU, with the exception of salivary gland cancers. The use of this technique is highly experimental at this time. Currently, the University of Washington Medical Cyclotron Facility in Seattle is the only clinical neutron facility in the United States.
The effectiveness of neutrons as treatment of choice in the treatment of salivary gland tumors was most recently confirmed by Stannard et al. (2013) with the treatment of 335 patients at IThemba Labs. The patients had either unresectable tumors or had gross macroscopic residual disease. Local regional control was 60.6% at 5 years and 39.1% at 10 years. Disease specific survival was 66.8% at 5 years and 53.7% at 10 years. A recent publication by Davis, et al. (2016) reported a 6 year overall survival of 58% in 140 patients, with the most common subtype being adenoid cystic carcinoma and the submandibular gland being the most common site. The current standard neutron dose was reported as 1.15 neutron Gray (nGy) 4 times per week for 4 weeks (total 18.4 nGy) equivalent to 60 to 70 Gy over 6 to 7 weeks with conventional photon radiation.
Neutrons do have limitations, especially at the skull base, which can result in an increased complication rate. Recent studies at the University of Washington (Douglas et. al, 2008; Rockhill and Laramore, 2016) have focused on reducing the neutron contribution at the superior portion of the tumor in skull-based tumors using SRS, Gamma Knife, as a boost. The 40 month actuarial control rate was 82% compared to a historical control rate of 39% with neutrons alone.]
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Neutron Beam Therapy
Neutron Beam Radiotherapy in Cancer Treatment
References:
- Aihara T, Morita N, Kamitani N, et al. Boron neutron capture therapy for advanced salivary gland carcinoma in head and neck. In J Clin Oncol. 2014 Jun; 19(3):437-444.
- American Society of Radiation Therapy (ASTRO) Coding Resource.
- Burmeister J, Spink R, Liang L, et al. Commissioning of intensity modulated neutron therapy (IMNRT). Med Phys. 2013 Feb; 40(2):021718.
- Davis C, Sikes J, Namaranian P, et al. Neutron beam radiation therapy: an overview of treatment and oral complications when treating salivary gland malignancies. J Oral Maxillofacial Surg. 2016 Apr; 74(4):830-835.
- Douglas JG, Goodkin R, and Laramore GE. Gamma knife stereotactic radiosurgery for salivary gland neoplasms with base of skull invasion following neutron radiotherapy. Head Neck. 2008 Apr; 30(4):492-496.
- Douglas JG, Laramore GE, Austin-Seymour M, et al. Treatment of locally advanced adenoid cystic carcinoma of the head and neck with neutron radiotherapy. Int J of Radiat Oncol Biol Phys. 2000 Feb 1; 46(3):551-557.
- Huber PE, Debus J, Latz D, et al. Radiotherapy for advanced adenoid cystic carcinoma: neutrons, photons or mixed beam? Radiotherapy and Oncology. 2001 May 1; 59(2):161-167.
- National Comprehensive Cancer Network (NCCN) Guidelines® Version 3.2019 – September 16, 2019 Head and Neck Cancers. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers 3.2019. 2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN®. To view the most recent and complete version of the NCCN Guidelines®, go online to NCCN.org.
- Prott FJ, Micke O, Haverkamp U et al. Results of fast neutron therapy of adenoid cystic carcinoma of the salivary glands. Anticancer Research. 2000 Sep-Oct; 20(5C):3743-9.
- Rockhill JK, Laramore GE. Chapter 20: Neutron Beam Radiotherapy. In: Gunderson L, Tepper J. editors. Clinical Radiation Oncology, 4th eds. Philadelphia, PA: Churchill Livingstone; 2016; (20):373-375.
- Stannard C, Vernimmen E, Carrara H, et al. Malignant salivary gland tumors: Can fast neutron therapy results point the way to carbon ion therapy? Radiother Oncol. 2013 Nov; 109(2):262-268.
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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