Appeal type: unknown
Decision: unknown

 
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 proton beam therapy (PBT) is a technology for delivering conformal external beam radiation 
with positively charged atomic particles to a well-defined treatment volume. PBT is approved by the U.S. Food 
and Drug Administration. Photon beams deposit their greatest amount of energy beneath the patient's surface 
with a gradual reduction in energy deposition along the beam path as photons pass through the target and then 
through an exit point out of the body. In contrast, the physical profile of a beam of proton particles allows for 
the majority of its energy to be deposited over a very narrow range of tissue at a depth largely determined by 
the energy of the proton beam. A proton beam deposits relatively less radiation energy upon entering the body 
compared to a photon beam. The energy deposition of the proton beam then rapidly increases over a narrow 
range of tissue at a desired depth to produce an intense dose distribution pattern called the Bragg peak. Beyond 
the Bragg peak, energy and dose deposition rapidly decrease, resulting in the absence of any significant exit 
dose deposited in normal tissue beyond the target. 
 
PBT can allow for radiation treatment plans that are highly conformal to the target volume. PBT planning 
defines the necessary field sizes, gantry angles and beam energies needed to achieve the desired radiation dose 
distribution. 
 
An assessment of patient suitability for PBT is an important step in the process of care. Changes in the density 
and composition of tissues in the path of the beam have much greater impact on the delivered dose for protons 
than photons. Tissue interfaces, especially those with large differences in electron density, can lead to larger or 
unacceptable dosimetric uncertainties in PBT for certain patients. 
 
PBT treatment planning is a multi-step process and shares functions common to other forms of external beam 
radiotherapy planning: 
 
    Simulation and Imaging: Three-dimensional image acquisition of the target region by simulation employing 
CT, CT/ PET and/or MR scanning equipment is an essential prerequisite to PBT treatment planning. If 
respiratory or other normal organ motion is expected to produce significant movement of the target region 
during radiotherapy delivery, the radiation oncologist may additionally elect to order multi-phasic treatment 
planning image sets to account for motion when rendering target volumes. 
    Contouring: Defining the target and avoidance structures is a multi-step process: 
        The radiation oncologist reviews the three-dimensional images and outlines the treatment target on each 
slice of the image set. The summation of these contours defines the Gross Tumor Volume (GTV). 
 Precise delivery is vital for proper treatment. Therefore, imaging techniques such as stereoscopic X-ray or CT 
scan (collectively referred to as Image Guided Radiation Therapy or IGRT) should be utilized to verify 
accurate and consistent patient and target setup for every treatment fraction. You can find these rules in the 
Local Coverage Determination (LCD) Proton Beam Therapy L35075. 
 
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.