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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 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 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 melanomas 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
Limitations In general, proton beam radiotherapy is not indicated for cancers that are widely disseminated, such as leukemias, have hematogenous metastases or as a short-term palliative procedure. The intent of treatment should be curative. If proton beam radiotherapy is used for a patient with metastatic disease, evidence should be provided to justify the expectation of a long-term benefit (greater than 2y), as well as evidence of a dosimetric advantage for proton beam radiotherapy over other forms of radiation therapy. All other indications are not considered reasonable and necessary and will be denied.
As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary. You can find this information in Medicare's Local Coverage Determination (LCD): Proton Beam Radiotherapy (L33937). If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.