Aetna · Clinical coverage policy

Aetna Proton Beam and Neutron Beam Radiotherapy coverage criteria

Aetna CPB 0270 covers proton beam radiotherapy as medically necessary only for curative treatment of a defined list of tumors (e.g., primary CNS, certain head/neck and skull-base tumors, pediatric malignancies, ocular/uveal melanoma, craniospinal-irradiation cases, and select others), and covers neutron beam therapy only for inoperable, locally advanced, or unresectable salivary gland tumors. Proton and neutron beam are experimental/investigational for all other indications, carbon ion therapy is experimental/investigational for all indications, and for localized prostate cancer proton beam and IMRT are deemed clinically equivalent (coverage governed by the member's benefit plan).

Policy CPB 0270 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0270

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0270 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Proton Beam and Neutron Beam Radiotherapy (CPT 77520), and what gets it denied?

Path
Aetna CPB 0270 covers proton beam radiotherapy as medically necessary only for curative treatment of a defined list of tumors (e.g., primary CNS, certain head/neck and skull-base tumors, pediatric malignancies, ocular/uveal melanoma, craniospinal-irradiation cases, and select others), and covers neutron beam therapy only for inoperable, locally advanced, or unresectable salivary gland tumors. Proton and neutron beam are experimental/investigational for all other indications, carbon ion therapy is experimental/investigational for all indications, and for localized prostate cancer proton beam and IMRT are deemed clinically equivalent (coverage governed by the member's benefit plan). Coverage criteria include: Proton beam radiotherapy (PBRT) is medically necessary for the CURATIVE treatment of ANY ONE of the following tumors (items below are alternatives, joined by 'or'); PBRT (curative) — Primary CNS tumors; PBRT (curative) — Head and neck tumors (T4 or unresectable, EXCLUDING T1-T2N0M0 laryngeal cancer); PBRT (curative) — Paranasal sinus, other accessory sinus, or nasopharyngeal tumors; PBRT (curative) — Skull-based tumors (e.g., chordomas or chondrosarcomas); PBRT (curative) — Malignancies in children (21 years of age and younger); PBRT (curative) — Esophageal cancer; PBRT (curative) — Malignancies requiring craniospinal irradiation (CSI) in persons with NO active malignancy outside of the craniospinal axis; PBRT (curative) — Mediastinal lymphomas; PBRT (curative) — Thymomas and thymic carcinoma; PBRT (curative) — Thoracic sarcomas; PBRT (curative) — Nonmetastatic retroperitoneal sarcomas; PBRT (curative) — Ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body and choroid); PBRT (curative) — Primary or metastatic tumors of the spine WHERE the spinal cord tolerance would be exceeded with photon radiotherapy approaches; PBRT (curative) — Primary malignant or benign bone tumors; PBRT (curative) — Reirradiation of an in-field or marginal recurrence being treated with curative intent, WHERE other radiotherapy approaches would exceed acceptable constraints; PBRT (curative) — Localized unresectable hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma in the curative setting WHEN documentation is provided that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy techniques, including IMRT, SBRT, selective internal radiation spheres, and transarterial therapy (for example, chemoembolization); PBRT (curative) — Non-metastatic pelvic tumors that are advanced and unresectable, with significant pelvic or periaortic non-metastatic bulky nodes, WHERE other radiotherapy approaches would exceed acceptable constraints; PBRT (curative) — Persons with a single kidney or transplanted pelvic kidney with treatment of an adjacent target volume AND in whom maximal avoidance of the organ is critical; PBRT (curative) — Persons with genetic syndromes making total volume of radiation minimization crucial, such as, but not limited to: NF-1 patients, BRCA1/2, deleterious ATM mutations, Li-Fraumeni, Lynch syndrome, and retinoblastoma; PBRT (curative) — Pituitary neoplasms; PBRT — Localized cancer of an intact prostate: Aetna considers proton beam radiotherapy and IMRT clinically equivalent. Medical necessity will be determined based on the terms of the member's benefit plan (check benefit plan descriptions); Neutron beam therapy is medically necessary for the treatment of ANY ONE of the following salivary gland tumors — Inoperable tumor; Neutron beam therapy (salivary gland) — Locally advanced tumor, especially in persons with gross residual disease; Neutron beam therapy (salivary gland) — Unresectable tumor. Applies to 11 codes: 77520, 77521, 77522, 77523, 77525, 61796, 61797, 61798, 61799, 63620, 63621.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For localized unresectable hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma in the curative setting: documentation must be provided that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy techniques, including intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), selective internal radiation spheres, and transarterial therapy (for example, chemoembolization).
Trap
Policy exclusions and limitations: Proton beam radiotherapy (PBRT) is experimental, investigational, or unproven for ALL OTHER indications, including the following indications in adults (over age 21) (not an all-inclusive list), because its effectiveness for these indications has not been established; PBRT EI — Age-related macular degeneration; PBRT EI — Angiosarcoma; PBRT EI — Bladder cancer; PBRT EI — Breast cancer; PBRT EI — Cardiac intimal sarcoma; PBRT EI — Carotid body tumor; PBRT EI — Cavernous hemangioma; PBRT EI — Cervical cancer; PBRT EI — Cholangiocarcinoma, extrahepatic; PBRT EI — Choroidal hemangioma; PBRT EI — Dermatofibrosarcoma protuberans; PBRT EI — Desmoid fibromatosis; PBRT EI — Desmoid tumor (aggressive fibromatosis); PBRT EI — Ewing's sarcoma; PBRT EI — Fibrosarcoma of the extremities; PBRT EI — Hemangioblastoma; PBRT EI — Hemangioendothelioma; PBRT EI — Hodgkin's lymphoma; PBRT EI — Intracranial arterio-venous malformations; PBRT EI — Large cell lymphoma; PBRT EI — Leiomyosarcoma of the extremities; PBRT EI — Liposarcoma; PBRT EI — Liver metastases (including liver metastases from carcinoid gastrinoma); PBRT EI — Lung cancer (including non-small-cell lung carcinoma); PBRT EI — Mesothelioma; PBRT EI — Multiple myeloma; PBRT EI — Non-Hodgkin lymphoma (except mediastinal lymphomas); PBRT EI — Non-uveal melanoma; PBRT EI — Palliative treatment; PBRT EI — Pancreatic cancer; PBRT EI — Prostate cancer, metastatic; PBRT EI — Rectal cancer; PBRT EI — Rhabdomyoma; PBRT EI — Rhabdomyosarcoma; PBRT EI — Seminoma; PBRT EI — Small bowel adenocarcinoma; PBRT EI — Soft tissue sarcoma; PBRT EI — Uterine cancer; PBRT EI — Yolk cell tumor; Neutron beam therapy is experimental, investigational, or unproven for ALL OTHER indications (other than the covered salivary gland tumors), including the malignancies listed below (not an all-inclusive list), because its effectiveness for these indications has not been established; Neutron beam EI — Colon cancer; Neutron beam EI — Dermatofibrosarcoma protuberans; Neutron beam EI — Ghost cell odontogenic carcinoma; Neutron beam EI — Glioma; Neutron beam EI — Kidney cancer; Neutron beam EI — Laryngeal cancer; Neutron beam EI — Lung cancer; Neutron beam EI — Pancreatic cancer; Neutron beam EI — Prostate cancer; Neutron beam EI — Rectal cancer; Neutron beam EI — Soft tissue sarcoma; Carbon ion therapy is experimental, investigational, or unproven for ALL indications because its effectiveness has not been established. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0270 — Proton Beam and Neutron Beam Radiotherapy

Coverage criteria

  • Proton beam radiotherapy (PBRT) is medically necessary for the CURATIVE treatment of ANY ONE of the following tumors (items below are alternatives, joined by 'or')
  • PBRT (curative) — Primary CNS tumors
  • PBRT (curative) — Head and neck tumors (T4 or unresectable, EXCLUDING T1-T2N0M0 laryngeal cancer)
  • PBRT (curative) — Paranasal sinus, other accessory sinus, or nasopharyngeal tumors
  • PBRT (curative) — Skull-based tumors (e.g., chordomas or chondrosarcomas)
  • PBRT (curative) — Malignancies in children (21 years of age and younger)
  • PBRT (curative) — Esophageal cancer
  • PBRT (curative) — Malignancies requiring craniospinal irradiation (CSI) in persons with NO active malignancy outside of the craniospinal axis
  • PBRT (curative) — Mediastinal lymphomas
  • PBRT (curative) — Thymomas and thymic carcinoma
  • PBRT (curative) — Thoracic sarcomas
  • PBRT (curative) — Nonmetastatic retroperitoneal sarcomas
  • PBRT (curative) — Ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body and choroid)
  • PBRT (curative) — Primary or metastatic tumors of the spine WHERE the spinal cord tolerance would be exceeded with photon radiotherapy approaches
  • PBRT (curative) — Primary malignant or benign bone tumors
  • PBRT (curative) — Reirradiation of an in-field or marginal recurrence being treated with curative intent, WHERE other radiotherapy approaches would exceed acceptable constraints
  • PBRT (curative) — Localized unresectable hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma in the curative setting WHEN documentation is provided that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy techniques, including IMRT, SBRT, selective internal radiation spheres, and transarterial therapy (for example, chemoembolization)
  • PBRT (curative) — Non-metastatic pelvic tumors that are advanced and unresectable, with significant pelvic or periaortic non-metastatic bulky nodes, WHERE other radiotherapy approaches would exceed acceptable constraints
  • PBRT (curative) — Persons with a single kidney or transplanted pelvic kidney with treatment of an adjacent target volume AND in whom maximal avoidance of the organ is critical
  • PBRT (curative) — Persons with genetic syndromes making total volume of radiation minimization crucial, such as, but not limited to: NF-1 patients, BRCA1/2, deleterious ATM mutations, Li-Fraumeni, Lynch syndrome, and retinoblastoma
  • PBRT (curative) — Pituitary neoplasms
  • PBRT — Localized cancer of an intact prostate: Aetna considers proton beam radiotherapy and IMRT clinically equivalent. Medical necessity will be determined based on the terms of the member's benefit plan (check benefit plan descriptions)
  • Neutron beam therapy is medically necessary for the treatment of ANY ONE of the following salivary gland tumors — Inoperable tumor
  • Neutron beam therapy (salivary gland) — Locally advanced tumor, especially in persons with gross residual disease
  • Neutron beam therapy (salivary gland) — Unresectable tumor

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • For localized unresectable hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma in the curative setting: documentation must be provided that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy techniques, including intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), selective internal radiation spheres, and transarterial therapy (for example, chemoembolization)

Frequently asked questions

When does Aetna cover Proton Beam and Neutron Beam Radiotherapy (CPT 77520), and what gets it denied?
Aetna CPB 0270 covers proton beam radiotherapy as medically necessary only for curative treatment of a defined list of tumors (e.g., primary CNS, certain head/neck and skull-base tumors, pediatric malignancies, ocular/uveal melanoma, craniospinal-irradiation cases, and select others), and covers neutron beam therapy only for inoperable, locally advanced, or unresectable salivary gland tumors. Proton and neutron beam are experimental/investigational for all other indications, carbon ion therapy is experimental/investigational for all indications, and for localized prostate cancer proton beam and IMRT are deemed clinically equivalent (coverage governed by the member's benefit plan). Coverage criteria include: Proton beam radiotherapy (PBRT) is medically necessary for the CURATIVE treatment of ANY ONE of the following tumors (items below are alternatives, joined by 'or'); PBRT (curative) — Primary CNS tumors; PBRT (curative) — Head and neck tumors (T4 or unresectable, EXCLUDING T1-T2N0M0 laryngeal cancer); PBRT (curative) — Paranasal sinus, other accessory sinus, or nasopharyngeal tumors; PBRT (curative) — Skull-based tumors (e.g., chordomas or chondrosarcomas); PBRT (curative) — Malignancies in children (21 years of age and younger); PBRT (curative) — Esophageal cancer; PBRT (curative) — Malignancies requiring craniospinal irradiation (CSI) in persons with NO active malignancy outside of the craniospinal axis; PBRT (curative) — Mediastinal lymphomas; PBRT (curative) — Thymomas and thymic carcinoma; PBRT (curative) — Thoracic sarcomas; PBRT (curative) — Nonmetastatic retroperitoneal sarcomas; PBRT (curative) — Ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body and choroid); PBRT (curative) — Primary or metastatic tumors of the spine WHERE the spinal cord tolerance would be exceeded with photon radiotherapy approaches; PBRT (curative) — Primary malignant or benign bone tumors; PBRT (curative) — Reirradiation of an in-field or marginal recurrence being treated with curative intent, WHERE other radiotherapy approaches would exceed acceptable constraints; PBRT (curative) — Localized unresectable hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma in the curative setting WHEN documentation is provided that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy techniques, including IMRT, SBRT, selective internal radiation spheres, and transarterial therapy (for example, chemoembolization); PBRT (curative) — Non-metastatic pelvic tumors that are advanced and unresectable, with significant pelvic or periaortic non-metastatic bulky nodes, WHERE other radiotherapy approaches would exceed acceptable constraints; PBRT (curative) — Persons with a single kidney or transplanted pelvic kidney with treatment of an adjacent target volume AND in whom maximal avoidance of the organ is critical; PBRT (curative) — Persons with genetic syndromes making total volume of radiation minimization crucial, such as, but not limited to: NF-1 patients, BRCA1/2, deleterious ATM mutations, Li-Fraumeni, Lynch syndrome, and retinoblastoma; PBRT (curative) — Pituitary neoplasms; PBRT — Localized cancer of an intact prostate: Aetna considers proton beam radiotherapy and IMRT clinically equivalent. Medical necessity will be determined based on the terms of the member's benefit plan (check benefit plan descriptions); Neutron beam therapy is medically necessary for the treatment of ANY ONE of the following salivary gland tumors — Inoperable tumor; Neutron beam therapy (salivary gland) — Locally advanced tumor, especially in persons with gross residual disease; Neutron beam therapy (salivary gland) — Unresectable tumor. Applies to 11 codes: 77520, 77521, 77522, 77523, 77525, 61796, 61797, 61798, 61799, 63620, 63621. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For localized unresectable hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma in the curative setting: documentation must be provided that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy techniques, including intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), selective internal radiation spheres, and transarterial therapy (for example, chemoembolization). Policy exclusions and limitations: Proton beam radiotherapy (PBRT) is experimental, investigational, or unproven for ALL OTHER indications, including the following indications in adults (over age 21) (not an all-inclusive list), because its effectiveness for these indications has not been established; PBRT EI — Age-related macular degeneration; PBRT EI — Angiosarcoma; PBRT EI — Bladder cancer; PBRT EI — Breast cancer; PBRT EI — Cardiac intimal sarcoma; PBRT EI — Carotid body tumor; PBRT EI — Cavernous hemangioma; PBRT EI — Cervical cancer; PBRT EI — Cholangiocarcinoma, extrahepatic; PBRT EI — Choroidal hemangioma; PBRT EI — Dermatofibrosarcoma protuberans; PBRT EI — Desmoid fibromatosis; PBRT EI — Desmoid tumor (aggressive fibromatosis); PBRT EI — Ewing's sarcoma; PBRT EI — Fibrosarcoma of the extremities; PBRT EI — Hemangioblastoma; PBRT EI — Hemangioendothelioma; PBRT EI — Hodgkin's lymphoma; PBRT EI — Intracranial arterio-venous malformations; PBRT EI — Large cell lymphoma; PBRT EI — Leiomyosarcoma of the extremities; PBRT EI — Liposarcoma; PBRT EI — Liver metastases (including liver metastases from carcinoid gastrinoma); PBRT EI — Lung cancer (including non-small-cell lung carcinoma); PBRT EI — Mesothelioma; PBRT EI — Multiple myeloma; PBRT EI — Non-Hodgkin lymphoma (except mediastinal lymphomas); PBRT EI — Non-uveal melanoma; PBRT EI — Palliative treatment; PBRT EI — Pancreatic cancer; PBRT EI — Prostate cancer, metastatic; PBRT EI — Rectal cancer; PBRT EI — Rhabdomyoma; PBRT EI — Rhabdomyosarcoma; PBRT EI — Seminoma; PBRT EI — Small bowel adenocarcinoma; PBRT EI — Soft tissue sarcoma; PBRT EI — Uterine cancer; PBRT EI — Yolk cell tumor; Neutron beam therapy is experimental, investigational, or unproven for ALL OTHER indications (other than the covered salivary gland tumors), including the malignancies listed below (not an all-inclusive list), because its effectiveness for these indications has not been established; Neutron beam EI — Colon cancer; Neutron beam EI — Dermatofibrosarcoma protuberans; Neutron beam EI — Ghost cell odontogenic carcinoma; Neutron beam EI — Glioma; Neutron beam EI — Kidney cancer; Neutron beam EI — Laryngeal cancer; Neutron beam EI — Lung cancer; Neutron beam EI — Pancreatic cancer; Neutron beam EI — Prostate cancer; Neutron beam EI — Rectal cancer; Neutron beam EI — Soft tissue sarcoma; Carbon ion therapy is experimental, investigational, or unproven for ALL indications because its effectiveness has not been established. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Proton Beam and Neutron Beam Radiotherapy?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: For localized unresectable hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma in the curative setting: documentation must be provided that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy techniques, including intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), selective internal radiation spheres, and transarterial therapy (for example, chemoembolization).
What does Aetna exclude for Proton Beam and Neutron Beam Radiotherapy?
Policy exclusions and limitations: Proton beam radiotherapy (PBRT) is experimental, investigational, or unproven for ALL OTHER indications, including the following indications in adults (over age 21) (not an all-inclusive list), because its effectiveness for these indications has not been established; PBRT EI — Age-related macular degeneration; PBRT EI — Angiosarcoma; PBRT EI — Bladder cancer; PBRT EI — Breast cancer; PBRT EI — Cardiac intimal sarcoma; PBRT EI — Carotid body tumor; PBRT EI — Cavernous hemangioma; PBRT EI — Cervical cancer; PBRT EI — Cholangiocarcinoma, extrahepatic; PBRT EI — Choroidal hemangioma; PBRT EI — Dermatofibrosarcoma protuberans; PBRT EI — Desmoid fibromatosis; PBRT EI — Desmoid tumor (aggressive fibromatosis); PBRT EI — Ewing's sarcoma; PBRT EI — Fibrosarcoma of the extremities; PBRT EI — Hemangioblastoma; PBRT EI — Hemangioendothelioma; PBRT EI — Hodgkin's lymphoma; PBRT EI — Intracranial arterio-venous malformations; PBRT EI — Large cell lymphoma; PBRT EI — Leiomyosarcoma of the extremities; PBRT EI — Liposarcoma; PBRT EI — Liver metastases (including liver metastases from carcinoid gastrinoma); PBRT EI — Lung cancer (including non-small-cell lung carcinoma); PBRT EI — Mesothelioma; PBRT EI — Multiple myeloma; PBRT EI — Non-Hodgkin lymphoma (except mediastinal lymphomas); PBRT EI — Non-uveal melanoma; PBRT EI — Palliative treatment; PBRT EI — Pancreatic cancer; PBRT EI — Prostate cancer, metastatic; PBRT EI — Rectal cancer; PBRT EI — Rhabdomyoma; PBRT EI — Rhabdomyosarcoma; PBRT EI — Seminoma; PBRT EI — Small bowel adenocarcinoma; PBRT EI — Soft tissue sarcoma; PBRT EI — Uterine cancer; PBRT EI — Yolk cell tumor; Neutron beam therapy is experimental, investigational, or unproven for ALL OTHER indications (other than the covered salivary gland tumors), including the malignancies listed below (not an all-inclusive list), because its effectiveness for these indications has not been established; Neutron beam EI — Colon cancer; Neutron beam EI — Dermatofibrosarcoma protuberans; Neutron beam EI — Ghost cell odontogenic carcinoma; Neutron beam EI — Glioma; Neutron beam EI — Kidney cancer; Neutron beam EI — Laryngeal cancer; Neutron beam EI — Lung cancer; Neutron beam EI — Pancreatic cancer; Neutron beam EI — Prostate cancer; Neutron beam EI — Rectal cancer; Neutron beam EI — Soft tissue sarcoma; Carbon ion therapy is experimental, investigational, or unproven for ALL indications because its effectiveness has not been established. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0270 — Proton Beam and Neutron Beam Radiotherapy

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0270 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.