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 state that proton beam therapy will be considered medically reasonable and necessary for the 
following conditions: 
Group 1 
 
        Unresectable benign or malignant central nervous system tumors to include but not limited to primary and 
variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign 
and atypical meningiomas, pineal gland tumors, and arteriovenous malformations 
        Intraocular melanomas 
        Pituitary neoplasms 
        Chordomas and chondrosarcomas 
        Advanced staged and unresectable malignant lesions of the head and neck 
        Malignant lesions of the Para nasal sinus, and other accessory sinuses 
        Unresectable retroperitoneal sarcoma 
        Solid tumors in children 
 
In addition to the criteria in Group I, Proton Beam Therapy indications must demonstrate that: 
 
        The Dose Volume Histogram (DVH) one or more critical structures or organs protected by the use of 
Proton Beam Therapy; 
        The dose to control or treat the tumor cannot be delivered without exceeding the tolerance of the normal 
tissue; 
        There is documented clinical rationale that doses generally thought to be above the level otherwise 
attainable with other radiation methods might improve control rates; or 
        There is documented clinical rationale that higher levels of precision associated with Proton Beam 
Therapy compared to other radiation treatments are clinically necessary. 
 
For the treatment of primary lesions, the intent of treatment must be curative. For the treatment of metastatic 
lesions, there must be 
 
        the expectation of a long-term benefit (greater than 2 year of life expectancy) that could not have been 
attained with conventional therapy, or 
        the expectation of a complete eradication or improved duration of control 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. 
 
            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 radiation. 
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 Medicare patients for continued coverage of the specific diagnosis. The protocol in and by itself 
does not constitute criteria for coverage. The presence of an Institutional Review Board (IRB) review when 
appropriate and patient informed consent are also expected. 
 
Group 2 
This section defines conditions that are still under investigation and would be covered when part of a clinical 
trial, registry or both. (See details in coding section) 
 
        Unresectable lung cancers and upper abdominal/peri-diaphragmatic cancers 
        Advanced stage, unresectable pelvic tumors including those with peri-aortic nodes or malignant lesions of 
the cervix 
        Left breast tumors 
        Unresectable pancreatic and adrenal tumors 
        Skin cancer with macroscopic perineural/cranial nerve invasion of skull base 
        Unresectable Malignant lesions of the liver, biliary tract, anal canal and rectum 
        Prostate Cancer, Non-Metastatic. 
 
You can find this information in the Local Coverage Determination (LCD) Proton Beam Therapy L36658. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.