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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 state that IMRT is clinically indicated (i.e., medical necessity criteria will be met) when highly conformal dose planning is required. IMRT planning may be clinically indicated when one or more of the following conditions are present:1.An immediately adjacent area has been previously irradiated and abutting portals must be established withhigh precision.2.Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors with conventional treatment.3.The target volume is concave or convex, and the critical normal tissues are within or around that convexity or concavity.4.The target volume is in close proximity to critical structures that must be protected.5.The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures.On the basis of the above conditions demonstrating medical necessity, disease sites that may support the use of IMRT include the following:-Primary, metastatic or benign tumors of the central nervous system including the brain, the brain stem, and spinal cord.-Primary or metastatictumors of the spine where the spinal cord tolerance may be exceeded with conventional treatment or where the spinal cord has previously been irradiated.-Primary, metastatic, benign or recurrent head and neck malignancies, including: orbits, sinuses, skullbase, aero-digestive tract, and salivary glands.-Thoracic malignancies.-Abdominal malignancies when dose constraints to small bowel or other normal abdominal tissue are exceeded and present administration of a therapeutic dose.-Pelvic malignancies including: prostatic, gynecological and anal carcinoma.-Other pelvic or retroperitoneal malignancies.Other malignancies not delineated in the above can be supported with submission of documentation for medical necessity should a denial occur.The determination of appropriateness and medical necessity for IMRT for any site shall be found in the documentation from the radiation oncologist and must be available when requested or submitted in the appeals process.The following are Limitations for IMRT:1.IMRT is not considered reasonable and necessary when at least one of the criteria listed above and one of the applicable ICD-10-CM diagnosis codes are not present. Refer to Billing and Coding: Intensity Modulated Radiation Therapy (IMRT), A56725, forapplicable CPT/HCPCS codes and diagnosis codes.2.ASTRO IMRT Model Policy outlines clinical scenarios that would not typically support the use of IMRT. These include:oWhere IMRT does not offer an advantage over conventional or three-dimensional conformal radiation therapy techniques that deliver good clinical outcomes and low toxicity.oClinical urgency, such as spinal cord compression, superior vena cava syndrome or airway obstruction.Palliative treatment of metastatic disease where the prescribed dose doesnot approach normal tissue tolerances.oInability to accommodate for organ motion, such as for a mobile lung tumor.oInability of the patient to cooperate and tolerate immobilization to permit accurate and reproducible dose delivery.There must be documented rationale of the advantage of IMRT versus the use of other radiation therapy methods in the medical record of each patient for whom IMRT is provided.You can find these rules in the Local Coverage Determination (LCD) for Intensity Modulated Radiation Therapy (IMRT), L36711. This LCD is effective for services provided on or after November 14, 2019.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.