Proton beam therapy (PBT) holds promise for pediatric patients, but level 1 evidence is not available. In this context, we examined insurance coverage decisions at our facility from 2010 to 2015. PBT was initially denied for 11% of pediatric cases. However, nearly all denials were overturned on appeal—a process that often delayed care by more than a week. Despite unfavorable language in coverage policies, real-world decisions were eventual approval in >99% of cases. Payers appear to have largely accepted the current level-of-evidence for pediatric PBT, but all parties spend significant time and resources on appeals. Streamlined approval processes could align incentives among stakeholders.