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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 the following are indications for Stereotactic Body Radiation Therapy (SBRT):
1. SBRT is indicated for primary tumors and tumors metastatic to the lung, liver, kidney, adrenal gland, or
pancreas.
2. SBRT is indicated for treatment of pelvic and head and neck tumors that have recurred after primary
irradiation.
3. SBRT is indicated for patients with clinically localized, low- to intermediate-risk prostate cancer.
4. SBRT treatment, of any body site or internal organ, is indicated for treatment of recurrence in or near
previously irradiated regions when a high level of precision and accuracy or a high dose per fraction is
indicated to minimize the risk of injury to surrounding normal tissues and treatment with conventional methods
is not appropriate or safe for the particular patient (medical records must describe the specific circumstances,
see documentation requirements in the attached Billing and Coding Article).
The following are limitations for Stereotactic Body Radiation Therapy (SBRT):
1. Primary treatment of lesions of bone, breast, uterus, ovary, and other internal organs not listed earlier in this
LCD as covered is not considered medically necessary.
2. SBRT is not considered medically necessary under the following circumstances for any condition:
a. Treatment is unlikely to result in clinical cancer control and/or functional improvement.
b. The tumor burden cannot be completely targeted with acceptable risk to critical normal structures.
c. The patient has a poor performance status (Karnofsky Performance Status less than 40 or Eastern
Cooperative Oncology Group (ECOG) Status of 3 or worse). Note that the higher a Karnofsky
Performance Status is, the better a patient is doing. However, the lower an Eastern Cooperative
Oncology Group (ECOG) Performance Status is, the better a patient is doing.
d. Recurrent (other than pelvic and head and neck tumors) or metastatic disease could be treated by
conventional methods (record must describe why other radiation therapy measures are not
appropriate or safe for the particular patient).
e. Since the goal of SBRT is to maximize the potency of the radiotherapy 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. SBRT is meant to represent a complete
course of treatment and not to be used as a boost following a conventionally fractionated course of
treatment.
You can find these rules in the Local Coverage Determination (LCD) for Stereotactic Radiation Therapy:
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT), L35076. This LCD is
effective for services provided on or after April 1, 2020.
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.