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 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 indications for Stereotactic Body Radiation Therapy (SBRT) are: 
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 rules say that the limitations for Stereotactic Body Radiation Therapy (SBRT) are: 
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 this information in the Local Coverage Determination (LCD): Stereotactic Radiation Therapy: 
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (L35076). 
 
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.