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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say Indications: Proton beam therapy will be considered medically reasonable and necessary for the
following conditions: Group 1: 1. Unresectable benign or malignant central nervous system tumors to include
but not limited to primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma,
craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations.
1. Intraocular melanomas. 1. Pituitary neoplasms. 1. Chordomas and chondrosarcomas. 1. Advanced staged and
unresectable malignant lesions of the head and neck. 1. Malignant lesions of the Para nasal sinus, and other
accessory sinuses. 1. Unresectable retroperitoneal sarcoma. 1. Solid tumors in children. In addition to the
criteria in Group I, Proton Beam Therapy indications must demonstrate that: The Dose Volume Histogram
(DVH) one or more critical structures or organs protected by the use of Proton Beam Therapy; The dose to
control or treat the tumor cannot be delivered without exceeding the tolerance of the normal tissue; There is
documented clinical rationale that doses generally thought to be above the level otherwise attainable with other
radiation methods might improve control rates; or, There is documented clinical rationale that higher levels of
precision associated with Proton Beam Therapy compared to other radiation treatments are clinically necessary.
For the treatment of primary lesions, the intent of treatment must be curative. For the treatment of metastatic
lesions, there must be; a. the expectation of a long-term benefit (greater than 2 year of life expectancy) that
could not have been attained with conventional therapy, or; a. the expectation of a complete eradication or
improved duration of control of the metastatic lesion that could not have been safely accomplished with
conventional therapy, as evidenced by a dosimetric advantage for proton beam radiotherapy over other forms
of radiation therapy. The patient's record demonstrates why Proton beam radiotherapy is considered the
treatment of choice for the individual patient. Specifically, the record must address the lower risk to normal
tissue, the lower risk of disease recurrence, and the advantages of the treatment over IMRT or 3- dimensional
conformal radiation. Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control
must be maintained. If the above provisions are met and the patient is treated in a protocol that is designed for
evidence development and for future publication, it is expected that future published data will support an
outcome advantage for Medicare patients for continued coverage of the specific diagnosis. The protocol in and
by itself does not constitute criteria for coverage. The presence of an Institutional Review Board (IRB) review
when appropriate and patient informed consent are also expected. Group 2: This section defines conditions that
are still under investigation and would be covered when part of a clinical trial, registry or both. (See details in
coding section). 1. Unresectable lung cancers and upper abdominal/peri-diaphragmatic cancers; 1. Advanced
stage, unresectable pelvic tumors including those with peri-aortic nodes or malignant lesions of the cervix; 1.
Left breast tumors; 1. Unresectable pancreatic and adrenal tumors; 1. Skin cancer with macroscopic
perineural/cranial nerve invasion of skull base; 1. Unresectable Malignant lesions of the liver, biliary tract, anal
canal and rectum; 1. Prostate Cancer, Non-Metastatic. You can find this information in Medicare's Local
Coverage Determination (LCD): Proton Beam Therapy (L36658).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.