Appeal type: unknown
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 state that stereotactic body radiation therapy (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 patients, or
b. Recurrent early stage lung cancer in medically inoperable patients, or
c. Early stage primary tumors in high operative risk patients, 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.

The patient's record must support the necessity and frequency of treatment. Medical records should include not only the standard history and physical but also the patient's functional status and a description of their current performance status (Karnofsky Performance Status or Eastern Cooperative Oncology Group Performance Status). For SBRT, a radiation oncologist must evaluate the clinical and technical aspects of the treatment and document and sign this evaluation as well as the resulting management decision. Clinical record documentation of the technical aspects of treatment planning and delivery should include details of the prescribed dose to the target and relevant dose-limiting normal structures and the actual dose delivered and dates of treatment delivery. The patient's record must demonstrate why SBRT 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 conventional radiation therapy, IMRT or 3-dimensional conformal radiation. Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control must be included. SBRT is not considered medically reasonable and necessary under the following circumstances:

1. Since the goal of SBRT is to maximize the potency of the radiation therapy by completing an entire course of treatment within an extremely accelerated time frame, any course of radiation treatment extending beyond five fractions is not considered SBRT and is not to be billed as such.
2. SBRT is meant to represent a complete course of treatment and not be used as a boost following a conventionally fractionated course of treatment.
3. Treatment is unlikely to result in clinical cancer control and/or functional improvement.
4. The tumor burden cannot be completely targeted with acceptable risk to nearby critical normal structures.
5. Patients with poor performance status (Karnofsky Performance Status less than 40 or ECOG Status of 3 or worse).

You can find these rules in Local Coverage Determination (LCD) Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (L33410).

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.