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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 CFR 422.101.The rules say that proton beam therapy is considered reasonable in instances where sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of added clinical benefit to the patient. Examples of such an advantage might be: 1. The target volume is in close proximity to one or more critical structures and a steep dose gradient outside the target must be achieved to avoid exceeding the tolerance dose to the critical structure(s).2. A decrease in the amount of dose inhomogeneity in a large treatment volume is required to avoid an excessive dose "hotspot" withinthe treated volume to lessen the risk of excessive early or late normal tissue toxicity.3. A photon-based technique would increase the probability of clinically meaningful normal tissue toxicity by exceeding an integral dose-based metric associated with toxicity.4. The same or an immediately adjacent area has been previously irradiated, and the dose distribution within the patient must be sculpted to avoid exceeding the cumulative tolerance dose of nearby normal tissue.You can find this rule in Local Coverage Determination (LCD): Proton Beam Therapy (L35075) -Effective November 7, 2019.The rules say that on the basis of the above medical necessity requirements and published clinical data, disease sites that frequently support the use of PBT include the following:GROUP 11. Ocular tumors, including intraocular melanomas2. Tumors that approach or are located at the base of skull, including but not limited to:-Chordoma-Chondrosarcomas-Primary or metastatic tumors of the spine where the spinal cord tolerance may be exceeded with conventional treatment or where the spinal cord has previously been irradiated3. Unresectable benign or malignant central nervous system tumors to include but not be limited to primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations4. Primary hepatocellular cancer treated in a hypofractionated regimen5. Primary or benign solid tumorsin children treated with curative intent and occasional palliative treatment of childhood tumors when at least one of the four criteria noted above apply6. Patients with genetic syndromes making total volume of radiation minimization crucial such as but not limited to NF-1 patients and retinoblastoma patients7. Pituitary neoplasm8. Advanced staged (e.g., T4) and/or unresectable malignant lesions of the head and neck9. Malignant lesions of the paranasal sinus, and other accessory sinuses10. Unresectable retroperitoneal sarcoma.You can find this rule in Local Coverage Determination (LCD): Proton Beam Therapy (L35075) -Effective November 7, 2019.The rules say that coverage of proton beam therapy in Group 2 is limited to providers who have demonstrated experience in data collection and analysis with a history of publication in the peer-reviewed medical literature.GROUP 2-Unresectable lung cancers and upper abdominal/peri-diaphragmatic cancers-Advanced stage, unresectable pelvic tumors including those with peri-aortic nodes or malignant lesions of the cervix-Breast cancers-Unresectable pancreatic and adrenal tumors -Skin cancer with macroscopic perineural/cranial nerve invasion of skull base-Unresectable malignant lesions of the liver, biliary tract, anal canal and rectum-Prostate cancer, without distant metastases-Hodgkin or Non-Hodgkin Lymphoma involving the mediastinum or in non-mediastinal sites where PBT has the potential to reduce the risk of pneumonitis or late effects of radiation therapy (secondary malignancy, cardiovascular disease, or other chronic health conditions)-Re-irradiation where prior radiation therapy to the site is the governing factor necessitating PBT in lieu of other radiotherapy.You can find this rule in Local Coverage Determination (LCD): Proton Beam Therapy (L35075) -Effective November 7, 2019.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordancewith Medicare rules.