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Decision: unknown

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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that SBRT will be considered medically reasonable and necessary for the following indications:  
1. Primary tumors and tumors metastatic to the lung when the following criteria are met:  
a. Early stage primary tumors in medically inoperable patients3, OR 
b. Recurrent early stage lung cancer in medically inoperable patients3, OR 
c. Early stage primary tumors in high operative risk patients3, OR 
d. Limited metastatic disease, good performance status, and the intention is eradicating all known 
active disease or greatly reducing the total disease burden in a manner that can extend 
progression-free survival. 
2. Primary tumors and tumors metastatic to the liver when the following criteria are met:  
a. Primary tumors when the patient is not a surgical candidate, OR 
b. Limited metastatic disease, good performance status, and the intention is eradicating all known 
active disease or greatly reducing the total disease burden in a manner that can extend 
progression-free survival. 
3. Primary tumors and tumors metastatic to the kidney when the following criteria are met:  
a. Primary tumors when the patient is not a surgical candidate, OR 
b. Limited metastatic disease, good performance status, and the intention is eradicating all known 
active disease or greatly reducing the total disease burden in a manner that can extend 
progression-free survival. 
4. Primary tumors and tumors metastatic to the adrenal gland when the following criteria are met:  
a. Primary tumors when the patient is not a surgical candidate, OR 
b. Limited metastatic disease, good performance status, and the intention is eradicating all known 
active disease or greatly reducing the total disease burden in a manner that can extend 
progression-free survival. 
5. Primary tumors and tumors metastatic to the pancreas when the following criteria are met:  
a. Primary tumors when the patient is not a surgical candidate, OR 
b. Limited metastatic disease, good performance status, and the intention is eradicating all known 
active disease or greatly reducing the total disease burden in a manner that can extend 
progression-free survival. 
 
 
 
6. Pelvic and head and neck tumors that have recurred after primary irradiation when the following criteria 
are met:  
a. The patient?s general medical condition (namely, the performance status) justifies aggressive, 
curative treatment to a primary, non-metastatic cancer, OR 
b. Metastatic disease requiring palliation cannot be treated by conventional methods due to 
proximity of adjacent prior irradiated volumes and other measures are not appropriate or safe for 
the particular patient, OR 
c. The patient?s general medical condition (namely, the performance status) justifies aggressive 
local therapy to one or more deposits of metastatic cancer in an effort either to achieve total 
disease clearance in the setting of oligometastatic disease or to reduce the patient?s overall 
burden of systemic disease for a specifically defined clinical benefit, AND 
d. The targeted tumor(s) can be completed encompassed with acceptable risk to nearby critical 
normal structures. 
7. Low to intermediate risk prostate cancer. 
8. Bone metastases in the vertebral bodies or the paraspinous region where extra care must be taken to 
avoid excess irradiation of the spinal cord when tumor-ablative doses are administered and when the 
following criteria are met:  
a. Limited metastatic disease, good performance status, and the intention is eradicating all known 
active disease or greatly reducing the total disease burden in a manner that can extend 
progression-free survival. 
9. Tumors arising in or near previously irradiated regions when a high level of precision and accuracy is 
required to minimize the risk of injury to surrounding normal tissues. 
10. Tumors requiring a high dose per fraction treatment above the level obtainable with other methods of 
radiation therapy. 
You can find this rule in the Medicare Program Integrity Manual, Chapter 13, Section 13.5.4. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.