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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 Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) are 
noninvasive means of administering high-dose radiotherapy to discreet tumor foci in cranial or extracranial 
locations, respectively. The two forms of treatment share certain overarching principles, namely, the use of 
image guidance and related treatment delivery technology for escalating the radiation dose to the tumor with as 
little radiation dose to the surrounding tissue as possible. Both methods are achieved with a stereotactic 
procedure during which a target lesion is localized relative to a known three-dimensional (3-D) reference 
system that allows for a high degree of anatomic accuracy. Examples of devices used for SRS and SBRT 
include a rigid head frame attached to a patient, a body frame with external reference markers in which a 
patient is securely positioned, fixed bony landmarks, a system of implanted fiducial markers that can be 
visualized with low-energy X-rays, and computed tomography (CT) imaging-based systems used to confirm 
the location of the tumor immediately prior to treatment. However, notable differences in clinical applications 
have emerged given the vastly different anatomic and clinical consideration between cranial and extracranial 
target lesions. 
 
Stereotactic Body Radiation Therapy (SBRT): is a radiation treatment modality that couples a high degree of 
anatomic targeting accuracy and reproducibility with very high doses of extremely precise, externally 
generated, ionizing radiation. The therapeutic intent of SBRT is to maximize cell-killing effect on the target(s) 
while minimizing radiation-related injury in adjacent normal tissues. SBRT is used to treat extra-cranial sites. 
 
SBRT Treatment Planning: 
Treatment planning for SBRT generally follows the same process and procedures as IMRT and 3-D conformal 
therapy plans. As with either treatment planning methods, SBRT planning determines the field size(s), gantry 
angles and other beam characteristics to achieve the desired radiation dose distribution. SBRT plans are highly 
customized to the target volume(s) and may be geometrically more accurate than conventionally fractionated 
external beam treatment plans.  
    Imaging  3-D image acquisition of the target region by simulation is an essential prerequisite to SBRT 
treatment planning. In general, a CT scan of the target region is performed and serves as the baseline image set 
used for dose calculations and, for selected cases, for coregistration of MRI or PET images sets in order to 
better define the target and surrounding anatomy. If respiratory or other normal organ motion is expected to 
produce significant movement of the target region during radiation therapy delivery, the radiation oncologist 
may additionally elect to order multiphasic treatment planning image sets to account for motion when 
rendering target volumes. Some SBRT treatment systems such as automated robotic delivery may not require 
multiphasic imaging but is still able to deliver breathing-corrected treatment.     Contouring - defining the target and avoidance structures is a multi-step process 
        The radiation oncologist reviews the 3-D images and outlines the treatment target on each slice of the 
image set. The summation of these contours defines the GVT. For multiple image sets, the physician may 
outline separate GTVs on each image set to account for the effect of normal organ motion upon target location 
and shape. Some patients may not have GTVs if they have had previous treatment with surgery or 
chemotherapy, in which case treatment planning will be based on CTVs. 
        The radiation oncologist draws a margin around the GTV to generate a CVT, which encompasses the 
areas at risk for microscopic disease (i.e., not visible on imaging studies). Other CTVs may be created based on 
the estimated volume of residual disease. For multiple image sets, the physician may draw this margin around 
an aggregate volume containing all image set GTVs to generate an organ-motion CTV, or Internal Target 
Volume (ITV). 
        To account for potential daily patient setup variation and/or organ and patient motion, a final margin is 
then added to create a PTV. 
        Nearby normal structures that could potentially be harmed by radiation (i.e., organs at risk or OARs) are 
also contoured. 
    Radiation dose prescribing - The radiation oncologist assigns specific dose requirements for the PTV, which 
typically includes a prescribed dose that must be given to at least 90 to 95 percent of the PTV. Additionally, 
PTV dose requirements routinely include dose constraints for the OARs (e.g., upper limit of mean dose, 
maximum allowable point dose and/or a critical volume of the OAR that must not receive a dose above a 
specified limit). A treatment plan that satisfies these requirements and constraints should maximize the 
potential for disease control and minimize the risk of radiation injury to normal tissue. 
    Dosimetric planning, calculations and dose verification - The medical physicist or a supervised dosimetrist 
calculates a multiple static beam and/or modulated arc treatment plan to deliver the prescribed radiation dose to 
the PTV and simultaneously satisfy the normal tissue dose constraints by delivering significantly lower doses 
to nearby organs. Dose-volume histograms are prepared for the PTV and OARs. Here, an arc is defined as a 
discrete complete or partial rotation of the linear accelerator gantry during which there is continuous motion of 
the MLC to deliver an optimized radiation dose distribution within the patient. The calculated beams or arcs are 
then delivered either to a phantom or a dosimetry measuring device to confirm that the intended dose 
distribution for the patient is physically verifiable and that the beams or arcs are technically feasible. 
 
You can find these rules in the Local Coverage Determination (LCD) Stereotactic Radiosurgery (SRS) and 
Stereotactic Body Radiation Therapy (SBRT) L33410. 
 
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.