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CIGNA HEALTHCARE COVERAGE POSITION
Subject Proton Beam Therapy for
Ocular Melanoma, Ocular
Hemangiomas and Macular
Degeneration
Table of Contents
Coverage Position............................................... 1
General Background ........................................... 1
Coding/Billing Information ................................... 7
References .......................................................... 7
Revised Date ........................... 12/15/2006
Original Effective Date ........... 12/15/2004
Coverage Position Number ............. 0253
Hyperlink to Related Coverage Positions
Pegaptanib (Macugen®)
Photodynamic Therapy for Ocular
Conditions
Transpupillary Thermal Therapy (TTT) for
Choroidal Tumors and Macular
Degeneration
INSTRUCTIONS FOR USE
Coverage Positions are intended to supplement certain standard CIGNA HealthCare benefit plans. Please note, the terms of a
participant’s particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage,
Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which
these Coverage Positions are based. For example, a participant’s benefit plan document may contain a specific exclusion related to
a topic addressed in a Coverage Position. In the event of a conflict, a participant’s benefit plan document always supercedes the
information in the Coverage Positions. In the absence of a controlling federal or state coverage mandate, benefits are ultimately
determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require
consideration of 1) the terms of the applicable group benefit plan document in effect on the date of service; 2) any applicable
laws/regulations; 3) any relevant collateral source materials including Coverage Positions and; 4) the specific facts of the particular
situation. Coverage Positions relate exclusively to the administration of health benefit plans. Coverage Positions are not
recommendations for treatment and should never be used as treatment guidelines. ©2006 CIGNA Health Corporation
Coverage Position
CIGNA HealthCare covers proton beam therapy as medically necessary for the treatment of
melanoma of the uveal tract (i.e., iris, ciliary body and choroid).
CIGNA HealthCare does not cover proton beam therapy for choroidal hemangiomas or macular
degeneration, because it is considered experimental, investigational or unproven.
General Background
Proton beam therapy (PBT) has been proposed for the treatment of melanomas of the uveal tract,
choroidal hemangiomas, and age-related macular degeneration. External beam radiation is used to
reduce recurrence of tumors after surgical excision or as a primary treatment for an inoperable mass. The
ability of radiation therapy to eradicate a tumor largely depends on the dose delivered to the cancer. The
necessity of delivering high radiation doses to improve local control rates has been demonstrated for a
variety of tumor types. However, high-energy photon beams from x-rays or gamma rays used for
conventional radiotherapy are characterized by a near-exponential decay of dose with depth. This means
that structures (i.e. normal tissues) in the entrance and exit regions receive large doses of irradiation as
well. The collateral dose to normal tissues can cause serious, debilitating or even fatal side effects. In
addition, the radiation dose to the proximal region of the target volume is greater than that in the distal
region, resulting in nonhomogeneous treatment, particularly for larger lesions (Verhey, Munzenrider,
1982; Loeffler, et al., 1997; Rossi, et al., 1998).
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In contrast, proton beam radiation therapy deposits the energy of the proton beam at the end of its path.
This region of maximum energy release is known as the Bragg peak. Since the depth of penetration of
the proton beam can be controlled, the radiation can be targeted almost exclusively to the tumor volume,
with minimal exposure of surrounding tissue. Thus, the improved dose distribution possible with PBT has
the potential to permit the delivery of higher target doses while delivering less radiation to sensitive
normal tissues. The relative biological effect (RBE) of protons is similar to that of x-rays and cobalt
gamma rays and is considered appropriate for treatment of human tissues (Verhey, Munzenrider, 1982;
Loeffler, et al., 1997; Rossi, et al., 1998; Paganetti, et al., 2002). In addition, proton beams offer potential
advantages over other modalities of stereotactic radiosurgery, such as gamma knife and linear
accelerators, particularly in treating lesions in critical, radiosensitive areas and in delivering a
homogenous dose to irregularly shaped lesions (Verhey, Munzenrider, 1982; Nicholson, DeVos, 1996;
Loeffler, et al., 1997).
The proton beam facility involves a synchrotron, a beam transport system, a beam delivery system,
isocentric gantries, and a patient alignment and imaging system, all under the operation of a facilitycontrol system. It is essential that the patient’s position not change during the procedure; therefore, the
patient is immobilized in a polyvinyl mold. Computed tomography (CT) scans, magnetic resonance
imaging (MRI), and positron emission tomography (PET), along with conventional x-rays, can be used to
visualize the target, and a computer-generated, three-dimensional (3D) model of the cancerous tissue is
constructed. This model, the digitally reconstructed radiograph (DRR), is used to decide the plan of
treatment (Verhey, Munzenrider, 1982; Tatsuzaki, Urie, 1991; Loeffler, et al., 1997).
Proton treatment facilities in the U.S. include: Loma Linda University Medical Center in Loma Linda,
California; Midwest Proton Radiation Institute at Indiana University, Indianapolis, Indiana; Northeast
Proton Therapy Center at the Massachusetts General Hospital, Boston, Massachusetts; and Proton
Therapy Center, M.D. Anderson University Cancer Center, Houston, Texas. The University of Florida in
Jacksonville and Hampton University in Virginia are currently constructing proton facilities (National
Association for Proton Therapy [NAPT]).
U.S. Food and Drug Administration (FDA)
Proton beam therapy systems are approved as a Class II device by the FDA 510(k) process as a “medical
device designed to produce and deliver a proton beam for the treatment of patients with localized tumors
and other conditions susceptible to treatment by radiation” (FDA, 2006). Examples of such systems are
the Optivus Proton Beam Therapy System (Optivus Technology Inc., Loma Linda, CA) and the IBA
Proton Therapy System-Proteus 235 (Ion Beam Applications S.A., Philadelphia, PA).
Melanoma of the Uveal Tract
Melanoma of the uveal tract (i.e., iris, ciliary body, and choroid), also called intraocular melanoma, has an
incidence of four cases per one million people each year in the United States. Light skin color, genetic
factors and environmental exposure are associated with an increased risk of developing uveal melanoma.
Melanomas may develop in the anterior uveal tract (i.e., the iris) or the posterior uveal tract (i.e., ciliary
body or choroids). Posterior tumors are generally more malignant, with the five-year mortality rate
secondary to metastasis being 30% compared to 2–3% for iris tumors.
Treatment of melanoma of the uveal tract depends upon the location, origin and size of the tumor,
presence or absence of extraocular invasion, extension and/or metastasis, and patient age. Conservative
treatment (i.e., observation with consistent follow-up) of iris melanoma is advocated, but local resection,
plaque radiotherapy (i.e., brachytherapy), and enucleation are considered standard treatment options.
PBT has been used effectively in a small number of patients with iris melanoma. Depending upon the
status of the tumor, ciliary body melanoma may be treated with plaque radiation therapy, external beam
charged-particle radiation therapy (e.g., PBT), local tumor resection or enucleation. Small choroidal
melanomas may be treated by observation, but other standard treatment options include: plaque radiation
therapy, external beam charged-particle radiation, laser photocoagulation, tumor resection and
enucleation. Treatment of medium and large choroidal melanomas will depend upon tumor characteristics
and extensiveness of the disease and may involve: radiation therapy (i.e., plaque radiation or charged
particle radiation); local-wall resection; or laser coagulation or transpupillary thermotherapy with plaque
therapy (NCI, 2006; Augsburger, et al., 2004). Eye-conserving treatment may be indicated when there is
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poor vision in the contralateral eye, contraindications to enucleation (e.g., patient’s health status, age), or
patient’s desire to retain the eye if at all possible. Plaque radiation and PBT are alternatives to
enucleation. In tumors located close to the optic nerve or fovea, nonradiation treatment is the first choice
to avoid poor visual outcomes. For smaller melanomas in close proximity to the optic disc, or tumors
unsuited for brachytherapy, PBT may be the treatment of choice; whereas, any type of radiation may be
appropriate for anterior tumors (Levin, et al., 2005; Char, et al., 2006; Conway, et. al., 2006; Smith, et al.,
2006).
Literature Review: The efficacy and safety of PBT for melanomas of the uveal tract has been assessed
in several studies available in the peer-reviewed medical literature. Studies included between 21 and
2645 patients with melanoma of the uveal tract. All patients received PBT as the sole treatment.
Melanomas of the uveal tract received average PBT doses ranging from 50–70 CGE (cobalt gray
equivalent) delivered in four to five daily fractions. The primary outcome measures included: eye
retention; incidences of recurrence, metastasis and cause-specific death; visual acuity; and
complications. Some studies also assessed possible risk and prognostic factors that could be used to
determine and define appropriate patient selection criteria. Lack of control or comparative treatment
groups, insufficiently defined patient selection criteria and lack of masked data analysis compromised the
quality of most studies.
In these studies, PBT was associated with good cause-specific survival (47.5–96%), eye retention (70–
95%), and local control (89–98%) for a time frame of 2–15 years. The rate of development of distant
metastases ranged from 7–24.2%. Risk analysis revealed that small tumor size and no ciliary body
involvement predicted eye retention (Munzenrider, et al., 1988). Tumor recurrence was associated with
larger tumor height and diameter, as well as with male sex (Kodjikian, et. al., 2004; Gragoudas, et al.,
1992; Wilson, Hungerford, 1999). Advanced tumor stage and large tumor height and diameter were
prognostic factors for the development of metastasis. A small tumor diameter predicted cause-specific
survival (Courdi, et al., 1999). Tumor basal area provided a predictive model for the risk of metastasisrelated death (Li, et al., 2003). In a large, retrospective risk analysis of 2069 consecutive patients with
intraocular melanoma, an algorithm was developed and used to calculate risk scores for metastatic death,
eye loss and vision loss (Gragoudas, et al., 2002). The results suggested that the risk score may be a
useful prognostic factor. Depending on the risk score, the 15-year rates of metastatic death, eye loss and
vision loss varied considerably, ranging from 35–95%, 7–100%, and 19–100%, respectively. However,
the validity of these models remains to be tested in a prospective clinical trial.
The incidences of various long-term complications associated with PBT were assessed in two
retrospective studies involving 218 and 480 patients (Guyer, et al., 1992; Lumbroso, et al., 2001,
respectively). Guyer et al. (1992) retrospectively assessed the incidence of radiation maculopathy
following PBT in 218 patients with choroidal melanoma. At three years following PBT, 89% of patients
developed radiation maculopathy, including macular edema (87% of patients), microvascular changes
(76% of eyes), intraretinal hemorrhages (70% of eyes) and capillary nonperfusion (64% of eyes).
Lumbroso et al. (2001) observed an increase in intraocular inflammation in 13% and 28% of patients at
the two-and five-year follow-ups, respectively, among patients with uveal melanoma. These results
suggested that PBT may be associated with late complications in a substantial number of patients, and
that monitoring for these possible side effects may be required.
The efficacy and safety of PBT were compared to the efficacy and safety of 125I or 106Ru episcleral plaque
(EP) brachytherapy in one retrospective study (Wilson, Hungerford, 1999). Patients who received PBT
experienced more loss of visual acuity and were at higher risk of developing distant metastases
compared to patients who received EP. However, local recurrence rates for PBT were equal to those for
125
I EP and lower than those for 106Ru EP brachytherapy. These results indicated that 125I EP may be the
preferred modality compared to PBT and 106Ru EP. However, this was a retrospective study of the
experience at a single clinical center. The criteria for choosing PBT versus EP may have been different,
and PBT patients may have had more advanced disease.
In a randomized, comparative trial, two doses of PBT (low dose = 50 CGE; high dose = 70 CGE) were
compared for the treatment of choroidal melanoma (Gragoudas, et al., 2000). The study involved 188
patients and had the statistical power of 80% to detect a 50% reduction, from 40% to 20%, in the rate of
visual loss and an increase in local recurrence from 3% to 12%. The five-year rates of local and systemic
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recurrence, metastasis, and enucleation were comparable for both groups. Complications occurred at
similar rates for patients in both groups, and included vitreous hemorrhage (13% and 15% for low-dose
and high-dose groups, respectively), subretinal exudation in macula (11% and 8%), posterior subcapsular
opacity (14% and 7%), radiation keratopathy (2% and 4%), and uveitis (0% and 1%). These results
suggested that, while dose escalation may not improve clinical outcomes, it does not significantly
increase complication rates.
Damato et al. (Sep, 2005) conducted a prospective, single-center, noncomparative study of PBT of 88
patients with iris melanoma, who were treated between 1993 and 2004. Median follow-up was 2.7 years
with a range of 1–4 years. Outcomes included visual acuity and complications. The most common posttreatment complication was the development of cataracts in 18 patients. The occurrence of other
complications was minimal, with each occurring in only 1–3 patients. Three eyes were eventually
enucleated. Visual acuity ranged from 20/17 (28%) to 20/200 (1%). The authors concluded that PBT was
well tolerated and is a “reasonable alternative to plaque radiotherapy or surgical resection”. Limitations of
the study are lack of randomization and comparison to other forms of treatment.
In another report, Damato et al. (Aug, 2005) conducted a prospective study of 349 consecutive patients
treated with PBT for choroidal melanoma. Outcomes were measured in terms of tumor recurrence, ocular
conservation, visual acuity, and metastatic death. Assessment tools included Snellen eye chart,
ophthalmologic examination, ultrasound, and color photography. Patients were selected for PBT based
upon tumor margins, location and size. Follow-up ranged from 1–5 years, with a median of 3.1 years.
Transpupillary thermotherapy was adjunctively given to 11 patients during PBT. Five-year actuarial rates
were reported for local tumor recurrence (3.5%), enucleation (9.4%), conservation of vision of counting
fingers (79.1%), visually acuity ≥ 20/200 (61.1%), visual acuity ≥ 20/40 (44.8%) and metastatic death
(10%). The authors concluded that PBT “achieves high rates of ocular conservation and local tumor
control in patients considered unsuitable for other forms of conservative treatment.” Limitations of the
study are lack of randomization and comparison to other forms of treatment.
Dendale et al. (2006) retrospectively reported on 1406 consecutive patients treated with PBT for uveal
melanoma. Outcomes were based upon visual acuity, local control rates, overall survival rates,
metastasis, and complications. Median follow-up was 73 months, with a range of 24–142 months. Fiveyear actuarial rates included: 1) 79% overall survival rate; 2) 80.6% metastasis-free rate; 3) 96% local
control rate; and 4) 7.7% enucleation due to complications. Complication rates were highest for
maculopathy and cataract. Other complications included papillopathy, glaucoma, keratits, vitreous
hemorrhage and intraocular inflammation. Visual acuity at five years remained stable for 38% of patients,
decreased for 56% of patients and improved in 6% of patients. The authors concluded that this study
“confirms that PBT ensures an excellent local control rate.” They stated that future research is needed to
try to reduce the ocular complication rate.
Other studies have proposed that PBT may be a treatment option for choroidal metastasis, recurrent
uveal melanoma, and extra-large choroidal or ciliochorodial melanomas. A small retrospective study
(n=49) by Tsina et al. (2005) reported that PBT was useful in the treatment of choroidal metastasis,
because “it allows retention of the globe, achieves a high probability of local tumor control and helps to
avoid pain and visual loss.” Marucci et al. (2006) conducted a prospective study of the treatment of PBT,
in lieu of enucleation, for recurrent uveal melanoma (n=31), and reported a 55% five-year eye retention
rate, with 27% useful vision. Although additional research is needed, the study suggested that PBT
resulted in good local control and low enucleation rate. Conway et al. (2006) conducted a retrospective
review including 21 patients with extra-large choroidal or ciliochoroidal melanomas who were not
candidates for other treatment options (e.g., brachytherapy and enucleation). The study reported a
probability rate of local control of 67%, and a clinically-assessed metastases-free survival rate, 24 months
following treatment, of 90%. The authors concluded that PBT is an option for extra-large uveal melanoma
in carefully selected patients who are unwilling to undergo primary enucleation. Limitations noted by the
authors included: PBT was not offered as an initial treatment; small sample size; and short-term follow-up.
Choroidal Hemangiomas
Choroidal hemangiomas are benign, vascular tumors that are generally small and well circumscribed, with
diameters of < 10 mm and thicknesses of < 3 mm. They may cause visual loss by exudative leakage,
which causes edema of the retina and subsequent retinal detachment. Patients may present with
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reduction in visual acuity, pain and the presence of “floaters,” secondary to exudative retinal detachment,
invasion of the macular region, cystoid macular edema, alteration of macular pigment epithelium, pigment
migration, subretinal fibrosis, and areolar macular atrophy. Early treatment is crucial to avoid the
development of cystoid macular edema and irreversible blindness. The standard treatment for choroidal
hemangiomas is laser photocoagulation. While this method successfully reattaches the retina, it does not
always completely destroy the tumor, and therefore, is associated with high recurrence rates. In recent
years, brachytherapy and external photon radiation have been investigated as a treatment option for
choroidal hemangiomas. In addition, PBT has been introduced as an alternative to laser photocoagulation. PBT shares the precise tumor targeting ability of brachytherapy but provides a more homogenous
radiation dose to the complete tumor, whereas in brachytherapy the base of the tumor receives a higher
dose than the apex (Zografos, et al., 1998; Hocht, et al., 2006).
Literature Review: PBT for choroidal hemangiomas was investigated in a small, uncontrolled,
comparative study of 53 patients. Patients received low (18–20 cobalt-gray equivalent [CGE]),
intermediate (25 CGE) or high (30 CGE) doses of PBT and were followed for six months to nine years.
Primary outcome measures included tumor regression, complication rates and changes in visual acuity.
Complete tumor regression was achieved in all patients, although tumor regression required two to three
years in patients who received low-dose PBT and only six months in those who received high-dose PBT.
Visual acuity was reduced in all high-dose PBT patients secondary to radiation-induced complications.
Complications associated with the treatment of choroidal hemangiomas included optic neuropathy in four
patients who received high-dose PBT (30 CGE) and telangiectases in one of three patients who received
intermediate-dose PBT (25 CGE). In contrast, patients who received low-dose PBT (18–20 CGE) did not
develop complications for at least one year (Zografos, et al., 1998).
Hocht et al. (2006) conducted a single-center, retrospective study of 44 consecutive patients with choroid
hemangiomas treated with photon therapy (n=19) or proton therapy (n=25). Outcomes were measured by
visual acuity, tumor thickness, resolution of retinal detachment, and post-treatment complications. Mean
follow-up was 38.9 months and 26.3 months, and median follow-up was 29 months and 23.7 months for
photon and proton patients, respectively. Tumor thickness was greater in the photon group than in the
proton group. Ninety-one percent of all patients were treated successfully. There was no significant
difference in the outcomes between the two groups. The authors concluded that “a benefit of proton beam
therapy could not be detected.”
Age-Related Macular Degeneration (AMD)
AMD is the leading cause of vision loss in people older than age 60. The main symptom is a gradual to
rapid loss of vision, especially the centrally focused vision required during reading and driving, that
eventually leads to blindness. There are two types of AMD, wet and dry. Wet AMD (i.e., neovascular)
occurs when abnormal blood vessels, posterior to the retina, grow underneath the macula, leak fluid and
blood, and cause displacement of the macula. Loss of central vision can occur quickly with wet AMD. The
classic early symptom is the perception of straight lines as wavy. Dry AMD (i.e., non-neovascular)
develops secondary to breakdown of the light-sensitive cells in the macula and is characterized by
increasingly blurred vision. Dry AMD is more common than wet AMD and occurs in 85% of all people with
intermediate to advanced AMD. Dry AMD precedes wet AMD. Risk factors include smoking, obesity,
white skin color, family history and female gender. AMD is diagnosed during a comprehensive eye
examination that includes visual acuity testing, dilated eye examination and tonometry. If the wet form of
AMD is suspected, a fluorescein angiogram may also be performed. Dry AMD is treated with antioxidants
(e.g., vitamin C, 500 mg; vitamin E, 400 IU [international units]; zinc oxide, 80 mg; cupric oxide, 2 mg).
The goal of this therapy is to slow disease progression. Wet AMD is usually treated with laser surgery,
photodynamic therapy or anti-VEGF (vascular endothelial growth factor) therapy (i.e., the injection of a
specific VEGF antagonist, such as pegaptanib, into the eye). PBT has been proposed as an alternative
treatment for wet AMD, based upon rationale from study results which suggest that proliferating vascular
cells are sensitive to low-dose radiation. The goal of PBT in treating wet AMD is the same as for laser or
photodynamic therapy, i.e., to destroy these vessels in order to allow retinal reattachment and a
stabilization or restoration of vision (Yonemoto, et al., 1996; National Eye Institute, 2006).
Literature Review: One randomized, sham-controlled, double-blinded clinical trial assessed PBT for the
treatment of exudative, subfoveal, choroidal, neovascular membranes secondary to age-related macular
degeneration (n=37) (Ciulla, et al., 2002). PBT patients received a total dose of 17.6 CGE in two fractions
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on two consecutive days. The primary outcome measure was the best-corrected visual acuity at six, 12,
18 and 24 months following treatment. This trial was halted for ethical reasons when FDA approval of
Visudyne® (QLT PhotoTherapeutics, Inc., Seattle, WA), a light-activated drug used in photodynamic
therapy, was anticipated. The sample size was, therefore, too small to detect a treatment effect. However,
visual acuity was stable for both groups during the first year of follow-up. At two years, PBT was
associated with a trend toward stabilization of visual acuity. This trend did not reach statistical
significance. No radiation-related side effects were reported.
In a small, prospective, uncontrolled, noncomparative study, PBT was evaluated for the treatment of
subfoveal, choroidal neovascularization in 21 patients age 51 or older (Yonemoto, et al., 1996). To
calculate the tumor dose volume, the authors utilized 3-D modeling to create a digital image of the eye. A
dose of 8 CGE was administered to the central macula in one fraction. At six months following treatment,
74% of patients experienced improved visual acuity, but severe loss of vision secondary to disease
progression was observed in one patient at one-year follow-up. No radiation-related acute or late
morbidity was observed.
Zambarakji et al. (2006) conducted a randomized clinical trial to determine the safety and visual
outcomes of PBT vs. photon therapy in 166 patients with subfoveal choroidal neovascularization
secondary to age-related macular degeneration. Visual acuity was assessed using Early Treatment
Diabetic Retinopathy Study charts, best-corrected visual acuity measurement, fluorescein angiography
and ophthalmological examination. No significant differences in visual acuity or complications were noted
between the two groups. Complications included radiation retinopathy, retinal hemorrhage, vascular
closure and arteriolar occlusion. The authors concluded that PBT may be considered for “patients in
whom approved therapies are not indicated and for those who are unable or unwilling to undergo multiple
fluorescein angiography examinations or intravitreal injections, and for the very elderly and infirm.” They
also stated that PBT may be a valuable adjuvant therapy, but studies are needed to validate this potential
use.
Professional Societies/Organizations
In their discussion of treatments for eye melanomas, the American Cancer Society (ACS) describes PBT
as one type of radiation therapy available to this patient population. They state that PBT can be aimed
very precisely, and results of treatment seem similar to those for brachytherapy (ACS, 2006).
The Collaborative Ocular Melanoma Study (COMS) sponsored by the National Eye Institute and the
National Cancer Institute of the National Institutes of Health state that PBT can be used to treat medium
choroidal melanoma. Good results have been achieved, but long-term outcomes are unknown (COMS,
2005).
The National Cancer Institute lists external beam, charged particle radiation therapy (e.g., PBT) as one of
several treatment options for ciliary body and choroidal melanoma (NCI, 2006).
The preferred practice guidelines published by the American Academy of Ophthalmology (AAO) do not
discuss PBT as a treatment option for ARMD. The guidelines discuss the surgical and postoperative care
of patients receiving thermal laser surgery, photodynamic therapy or intravitreal injections (AAO, 2006).
Summary
There is evidence in the peer-reviewed literature obtained from large-scale, uncontrolled studies
indicating that proton beam therapy (PBT) has clinical utility in the treatment of melanomas of the uveal
tract (i.e., iris, ciliary body and choroid). Although lack of control or of comparative treatment groups limited
the quality of most studies, it should be taken into consideration that most of these patients have few other
treatment options. If left untreated, these conditions would result in complete loss of vision or require
enucleation, or the patients could die secondary to distant metastasis. Therefore, the increase in patient
survival, tumor control and eye retention observed in these studies can be attributed to the treatment.
There is insufficient evidence in the peer-reviewed literature supporting the use of PBT for the treatment of
choroidal hemangiomas and age-related macular degeneration (AMD). Studies are limited, and conclusions
cannot be made regarding the safety, efficacy or appropriate clinical role of PBT for these conditions.
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Coding/Billing Information
Note: This list of codes may not be all-inclusive.
Covered when medically necessary:
CPT®*
Codes
77520
77522
77523
77525
HCPCS
Codes
S8030
ICD-9-CM
Diagnosis
Codes
190.0
190.6
Description
Proton beam delivery; simple, without compensation
Proton beam delivery; simple, with compensation
Proton beam delivery; intermediate
Proton beam delivery; complex
Description
Scleral application of tantalum ring(s) for localization of lesions for proton beam
therapy
Description
Malignant neoplasm of eyeball, ciliary body, iris
Malignant neoplasm of eye, choroid
Experimental/Investigational/Unproven/Not Covered:
ICD-9-CM
Description
Diagnosis
Codes
362.50
Macular degeneration (senile), unspecified
362.51
Nonexudative senile macular degeneration
362.52
Exudative senile macular degeneration
*
Current Procedural Terminology (CPT®) ©2005 American Medical Association: Chicago, IL.
References
1. Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG, editors. Intraocular
neoplasia. In: Abeloff: Clinical Oncology, 3rd ed 2004. Orlando: W.B. Saunders; 2004.
2. American Academy of Ophthalmology. Summary benchmarks for preferred practice patterns™.
Age-related macular degeneration (initial and follow-up evaluation). Nov 2006. Accessed Oct 30,
2006. Available at URL address:
http://www.aao.org/education/library/benchmarks/loader.cfm?url=/commonspot/security/getfile.cf
m&PageID=13240
3. American Cancer Society (ACS). Detailed guide: eye cancer. Radiation therapy. Oct 16, 2006.
Accessed Oct 30, 2006. Available at URL address:
http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Radiation_Therapy_74.asp?rnav=cri
4. Augsburger JJ, Damato BE, Bornfeld N. Uveal Melanoma. In: Yanoff: ophthalmology. 2nd ed. St.
Louis, Mosby. 2004.
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5. Char DH, Phillips T, Daftari I. Proton teletherapy of uveal melanoma. Int Ophthalmol Clin. 2006
Winter;46(1):41-9.
6. Ciulla TA, Danis RP, Klein SB, Malinovsky VE, Soni PS, Pratt LM, et al. Proton therapy for
exudative age-related macular degeneration: a randomized, sham-controlled clinical trial.
Am J Ophthalmol. 2002;134(6):905-6.
7. Collaborative Ocular Melanoma Study. About Choroidal Melanoma. 2005. Accessed Nov 2, 2006.
Available at URL address: http://www.jhu.edu/wctb/coms/booklet/book2.htm#hdg1
8. Conway RM, Poothullil AM, Daftari IK, Weinberg V, Chung JE, O'Brien JM. Estimates of ocular
and visual retention following treatment of extra-large uveal melanomas by proton beam
radiotherapy. Arch Ophthalmol. 2006 Jun;124(6):838-43.
9. Courdi A, Caujolle JP, Grange JD, Diallo-Rosier L, Sahel J, Bacin F, et al. Results of proton
therapy of uveal melanomas treated in Nice. Int J Radiat Oncol Biol Phys. 1999;45(1):5-11.
10. Damato B, Kacperek A, Chopra M, Campbell IR, Errington RD. Proton beam radiotherapy of
choroidal melanoma: the Liverpool-Clatterbridge experience. Int J Radiat Oncol Biol Phys. 2005
Aug 1;62(5):1405-11.
11. Damato B, Kacperek A, Chopra M, Sheen MA, Campbell IR, Errington RD. Proton beam
radiotherapy of iris melanoma. Int J Radiat Oncol Biol Phys. 2005 Sep 1;63(1):109-15.
12. Dendale R, Lumbroso-Le Rouic L, Noel G, Feuvret L, Levy C, Delacroix S, Meyer A, Nauraye C,
Mazal A, Mammar H, Garcia P, D'Hermies F, Frau E, Plancher C, Asselain B, Schlienger P,
Mazeron JJ, Desjardins L. Proton beam radiotherapy for uveal melanoma: results of Curie
Institut-Orsay proton therapy center (ICPO). Int J Radiat Oncol Biol Phys. 2006 Jul 1;65(3):780-7.
Epub 2006 May 2.
13. Gragoudas ES, Marie Lane A. Uveal melanoma: proton beam irradiation. Ophthalmol Clin North
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