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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 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
Because many radiological oncologists believe that proton beam therapy is a legitimate treatment option in
certain circumstances where 3-dimensional conformal or intensity modulated radiation therapy (IMRT) is
deemed medically necessary, proton beam therapy will be considered as medically reasonable and necessary
for certain other conditions (i.e., Group #2 of ICD-10-CM Codes that Support Medical Necessity) not listed
above, as long as the following criteria are met:
Either #1, #2, or #3 must be present and
Either #4 or #5 must be present and
#6 must always be present.
1. When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with
other indicated methods
2. When there is a reason to believe that doses generally thought to be above the level otherwise attainable with
other methods might improve control rates
3. In circumstances when the higher levels of precision associated with proton beam therapy as compared to
other radiation methods are necessary, i.e., clinically relevant
4. For the treatment of primary lesions, the intent of treatment must be curative
5. For the treatment of metastatic lesions, there must be
the expectation of a long-term benefit (> 2y) that could not have been attained with conventional therapy
the expectation of a complete eradication of the metastatic lesion that could not have been safely accomplished
with conventional therapy, as evidenced by a dosimetric advantage for proton beam radiotherapy over other
forms of radiation therapy
6. The patient's record demonstrates why Proton beam radiotherapy 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 IMRT or 3-dimensional conformal Dosimetric
evidence of reduced normal tissue toxicity and/or improved tumor control must be maintained.
If the above provisions are met and the patient is treated in a protocol that is designed for evidence
development and for future publication, it is expected that future published data will support an outcome
advantage for patients for continued coverage of the specific diagnosis. The protocol in and by itself does not
constitute criteria for coverage. The presence of an Institutional Review Board review, when appropriate, and
patient informed consent are also expected.
Proton beam treatment of the following conditions may be considered medically reasonable and necessary only
if the above criteria are met as specified.
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.
All other indications are not considered reasonable and necessary and will be denied.
You can find these rules in 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.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.