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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 proton beam radiotherapy is a type of particle beam radiation therapy that delivers high dose 
radiation to a localized site. Proton beams theoretically deposit less radiation in normal non-targeted tissues 
than conventional radiation therapy and have been used to escalate the radiation dose to diseased tissues while 
minimizing damage to adjacent normal tissues. Historically, proton beam radiotherapy has most commonly 
been used for tumors that are difficult or dangerous to treat with surgery or for tumors that are located next to 
vital structures, where administration of adequate doses of conventional radiation is difficult or impossible. 
 
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 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 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 patients 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. Proton beam treatment of the following conditions may be considered 
medically reasonable and necessary only if the above criteria are met as specified. You can find these rules in 
the 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.