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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 state that Polyethylene-glycol (PEG) hydrogel is covered ONCE in patients with clinically localized 
prostate cancer with BOTH the following:  
1. Inclusion criteria including ALL of the following: 
a. Low* or Favorable Intermediate Prostate Cancer Risk Group AUA or NCCN criteria 
b. Dose escalated ( 76 Gy) conventional fractionation (1.8-2 Gy fractions) or moderate 
hypofractionation (HFX) (2.4-3.4 Gy fractions) IG-IMRT planned 
c. Eastern Cooperative Oncology Group (ECOG) performance status  1 
d. Modern localization techniques insufficient to improve oncologic cure rates and/or reduce side 
effects due to AT LEAST ONE of the following: 
i. Anatomic geometry precluding ideal rectal constraints  
o Conventional fractionation (V70 <10%, V65 <20%, V40 <40%) 
o Moderate HPX (dose constraints not yet standardized; employ those used in the 
supporting phase III trials) 
ii. Medication usage (e.g., anticoagulants)  
iii. Comorbid conditions (e.g., increased age, Hx MI or CHF) 
2. No Exclusion criteria including ALL of the following: 
a. Less than 5 year life-expectancy and asymptomatic 
b. Prior prostate cancer treatment (surgery or RT) 
c. Active bleeding disorder or clinically significant coagulopathy 
d. Active inflammatory or infectious disease in the perineum or injection area (e.g., prostatitis, 
anorectal IBD) 
e. Prostate volume > 80 cc 
*Life expectancy  20 y (very low risk);  10 y (low risk) 
Prostate rectal spacers are various materials or devices placed between the prostate and anterior wall of the 
rectum for use in men receiving radiation therapy for prostate cancer. The anterior wall of the rectum is considered a major dose-limiting factor in radiation therapy of prostate cancer. Physical separation is proposed 
to allow reduced toxicity and treatment intensification. 
in summary, some of the literature endorses that the injection of the PEG spacer is usually safe and without 
untoward events once the physician becomes familiar with the procedure. Other references not cited here have 
described materials used to increase the distance between the prostate and rectum during radiation therapy for 
prostate cancer. Hyaluronic acid, human collagen, interstitial balloons, as well as synthetic polyethylene 
glycols have been used. National PEG spacer commercial coverage varies from none as investigational, to 
selective, to relatively unrestricted. Other MACs have not weighed in with either specific positive or negative 
coverage. Reducing rectal radiation exposure during prostate cancer radiotherapy is desirable. The PEG spacer 
can be considered selectively when state-of-the-art localization techniques do not suffice to either improve 
oncologic cure rates or reduce side effects. Coverage criteria are meant to reflect a balanced nexus between 
EBRT candidacy, PEG spacer RCT inclusion/exclusion criteria, and national society guideline support. You 
can find this rule at the Medicare Local Coverage Determination (LCD) L37485: Prostate Rectal Spacers. 
 
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.