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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 
methods of delivering ionizing radiation using highly focused convergent beams to target a lesion while 
limiting exposure of adjacent structures. 
 
Stereotactic describes target lesion localization relative to a known three-dimensional reference system that 
allows for a high degree of anatomic accuracy and precision. Devices used for stereotactic guidance may 
include a body frame with external reference markers in which a patient is positioned securely, a system of 
implanted fiducial markers that can be visualized with low-energy (kV) x-rays, and computed tomography 
(CT)-imaging-based systems used to confirm the location of a tumor immediately prior to treatment. 
 
SBRT is used to treat extra-cranial sites as opposed to stereotactic radiosurgery (SRS) which is used to treat 
intra-cranial and spinal targets. Treatment of extra-cranial sites excluding the spinal cord and related spinal 
structures requires accounting for internal organ motion as well as for patient motion. Thus, reliable 
immobilization or repositioning systems must often be combined with devices capable of decreasing organ 
motion or accounting for organ motion e.g., respiratory gating. Additionally, all SBRT is performed with at 
least one form of image guidance to confirm proper patient positioning and tumor localization prior to delivery 
of each fraction. 
 
SBRT is only indicated as primary treatment for tumor types or locations where the available published 
literature supports an outcome advantage over other conventional radiation modalities. 
 
SBRT may be delivered in one to five sessions (fractions). Each fraction requires an identical degree of 
precision, localization and image guidance. 
 
SRS is typically performed in a single session, using a rigidly attached stereotactic guiding device, other 
immobilization technology and/or a stereotactic-guidance system. 
 
The higher a Karnofsky Performance Status, the better a patient is doing. 
 The lower an Eastern Cooperative Oncology Group (ECOG) Performance Status is, the better a patient is 
doing. This is the opposite of the Karnofsky Performance scores where a lower score reflects a poorer status. 
 
SRS/SBRT procedures include the following components: 
 
Planning 
Position stabilization (attachment of a frame or frameless) 
Imaging for localization (CT, magnetic resonance imaging (MRI), angiography, positron emission tomography 
(PET), etc.) 
Computer assisted tumor localization (i.e. Image Guidance) 
Treatment planning  number of isocenters, number, placement and length of arcs or angles, number of beams, 
beam size and weight, etc. 
Isodose distributions, dosage prescription and calculation 
Setup and accuracy verification testing 
Simulation of prescribed arcs or fixed portals 
Radiation treatment delivery 
Indications for SRS/SBRT (for Cranial and Spinal Lesions): 
 
You can find these rules 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.