Does Medicare Cover Proton Therapy?

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  • Does Medicare cover proton therapy? Find out who is a candidate for proton therapy through Medicare and how much you'll need to pay with and without insurance.

Proton therapy is a relatively modern treatment for certain cancers that may cause fewer adverse effects than more established treatment pathways. It's often recommended for treating cancer in children because it causes less damage to rapidly growing tissues than regular radiotherapy. 

Proton therapy is expensive by any measure and is significantly more costly than radiotherapy. Therefore, many people worry about how to cover the costs if their doctor recommends proton therapy to treat their cancer. Does Medicare cover proton therapy? Below, you can find out who is eligible for proton therapy through Medicare. 

Does Medicare Cover Proton Therapy?

Medicare may cover proton beam therapy to treat cancer if it is the most appropriate treatment for your condition and health status. You will need to meet various eligibility criteria to qualify for proton beam therapy funding through Medicare. Generally, Medicare will pay up to 80% of your approved costs if you're eligible. 

Qualifying beneficiaries will have their therapy funded through Medicare Part A if they are treated as an inpatient and Part B if they are treated as an outpatient. Enrollees will be required to pay deductibles, coinsurance and copayments. Enrolling in a secondary health insurance scheme such as Medigap can help you cover your financial liabilities. 

Who Is a Candidate for Proton Therapy Through Medicare?

Medicare may consider funding proton beam therapy for certain types of cancer where there is a strong body of evidence to support its efficacy, such as solid tumors in children and central nervous system tumors. For types of cancer with limited evidence available, Medicare may provide funding if the beneficiary is enrolled in a clinical study. Medicare will not consider paying for treatment unless the therapy delivery system is FDA-approved.

Your doctor must provide evidence that there is a strong rationale for using proton beam therapy to treat your cancer instead of more conventional treatments. If you're being treated for a primary lesion, your medical team must certify that you can have a reasonable expectation of being cured using the protocol. If you have secondary lesions, you will need to provide evidence that proton beam therapy would likely either eliminate your lesions or make them significantly easier to control, resulting in at least 2 years of added life expectancy.

How Much Does Proton Therapy Cost Without Insurance?

As of 2017, a course of proton beam therapy costs between $30,000 and $120,000. However, exact costs will vary depending on various factors, including the size and location of the tumor and the treatment duration. As the costs of proton beam therapy are unaffordable for many Americans, it's wise to maintain health care insurance coverage that includes cancer treatments like proton beam therapy.

What Is Proton Therapy?

Proton therapy is a form of radiotherapy that uses protons to kill cancer cells. Protons are particles with a positive charge that can penetrate deep into the body to target cancerous lesions. Unlike regular radiotherapy, proton therapy minimizes the exposure of the surrounding tissues to radiation. 

Proton beam therapy is often performed as an outpatient treatment. During treatment, the affected individual is positioned carefully and a proton beam is directed accurately towards their tumor. Physicians may take medical images such as X-rays during treatment to ensure that the person adopts exactly the same position each time. It's important to stay still during proton beam therapy so that the beam penetrates the correct area. 

Proton beam therapy doesn't hurt at the point of treatment, but the surrounding skin may feel sore and irritated for a while afterward. Proton beam therapy is often used in conjunction with other cancer treatments, such as chemotherapy and radiotherapy, which may cause further side effects. 

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