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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 that proton beam therapy will be considered medically reasonable and necessary for the following conditions:Group #1 Conditions-Benign or malignant conditions otherwise not suitable for intensity modulated radiation therapy (IMRT) or 3-dimensional conformal therapy involving the base of the skull or axial skeleton, including but not limited to chordomas and chondrosarcomas.-Solid tumors in children up to age 18.-Benign or malignant central nervous system tumors to include primary and variant forms of medulloblastoma, astrocytoma, glioblastoma, arteriovenous malformations, acoustic neuroma craniopharyngioma, benign and atypical meningiomas and pineal gland tumors.-Intraocular melanomasBecause many radiological oncologists believe that proton beam therapy is a legitimate treatment option in certain circumstances where 3-dimensional conformal or intensity modulated radiation therapy (IMRT) is deemed medically necessary, proton beam therapy will be considered as medically reasonable and necessary for certain other conditions (i.e., Group #2 of ICD-10-CM Codes that Support Medical Necessity) not listed above, as long as the following criteria are met:Either #1, #2, or #3 must be present andEither #4 or #5 must be present and#6 must always be present.1. When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with other indicated methods2. When there is a reason to believe that doses generally thought to be above the level otherwise attainable with other methods might improve control rates3. In circumstances when the higher levels of precision associated with proton beam therapy as compared to other radiation methods are necessary, i.e., clinically relevant4. For the treatment of primary lesions, the intent of treatment must be curative5. For the treatment of metastatic lesions, there must bethe expectation of a long-term benefit (more than 2y) that could not have been attained with conventional therapythe expectation of a complete eradication 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 therapy6. 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 Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control must be maintained.Group #2 Conditions-Malignant lesions of the head and neck when the intent of treatment is to be curative.-Malignant lesions of the Para nasal sinus, and other accessory sinuses-Malignant lesions of the prostate-Malignant advanced stage, non-metastatic tumors of the bladder-Advanced pelvic tumors including malignant lesions of the cervix-Left breast tumors-Pancreatic and adrenal tumors-Skin cancer with perineural/cranial nerve invasion -Unresectable retroperitoneal sarcoma and extremity sarcoma-Cancers of the lung and upper abdominal/peri-diaphragmatic cancers-Malignant lesions of the liver, biliary tract, anal canal and rectum You can find this rule in the Local Coverage Determination for Proton Beam Radiotherapy, L33937 (eff 12/16/19).