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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.1, 2 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.1, 2  However, notable differences in clinical 
applications have emerged given the vastly different anatomic and clinical consideration between cranial and 
extracranial target lesions. 
 
This LCD recognizes these two distinct treatment approaches: 
 
Stereotactic Radiosurgery (SRS): is defined as radiation therapy delivered in one to five fractions via 
stereotactic guidance, with approximately 1mm targeting accuracy to intracranial targets and selected tumors 
around the base of the skull. SRS combines anatomic accuracy and reproducibility with very high doses of 
highly precise, externally generated, ionizing radiation, thereby maximizing the ablative effect on the target(s) 
while minimizing collateral damage to adjacent tissues. To assure quality of patient care, the procedure 
involves a multidisciplinary team consisting of a neurosurgeon, radiation oncologist and medical physicist. For 
tumors involving the skull base, the multidisciplinary team may include a head and neck surgeon with training 
in SRS.  
All SRS procedures include the following components: 
    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  
 
SRS Treatment Planning:  
SRS treatment plans are highly customized to the target volume(s) and may be geometrically more accurate 
than conventionally fractionated external beam treatment plans.  
    Immobilization - the patient is immobilized via a frame affixed to the skull or a stereotactic mask fixation 
system (frameless). 
    Imaging - 3-D image acquisition of the target region by simulation is an essential prerequisite to SRS 
treatment planning. In general, a CT or MRI of the target region is performed and serves as the baseline image 
set used for dose calculations and, in selected cases in which a CT was performed, for co-registration of MRI 
image sets in order to better define the target and surrounding anatomy. 
    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. A neurosurgeon may be involved in the contouring process. The summation of these contours 
defines the Gross Tumor Volume (GTV). Some patients may not have GTVs if they have had previous 
treatment with surgery, in which case treatment will be based on a Clinical Target Volume (CTV). 
        The radiation oncologist may draw a margin around the GTV or surgical bed to generate a CTV, which 
encompasses the areas at risk for microscopic disease (i.e., not visible on imaging studies).         To account for potential uncertainty in patient immobilization and/or imaging, a final margin is then added 
to create a Planning Target Volume (PTV). 
        Nearby normal structures that could potentially be harmed by radiation (i.e., organs at risk or OARs) are 
also contoured. 
 
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.2 The therapeutic intent of SBRT is to maximize cell-killing effect on the target(s) 
while minimizing radiation-related injury in adjacent normal tissues.2 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. 
     
Covered Indications 
SRS will be considered medically reasonable and necessary for the following indications:  
    Primary central nervous system malignancies, generally used as a boost or salvage therapy for lesions <5cm. 
    Primary and secondary tumors involving the brain parenchyma, meninges/dura, or immediately adjacent 
bony structures. 
    Benign brain tumors such as cranial meningiomas, acoustic neuromas, other schwannomas, pituitary 
adenomas, pineocytomas, craniopharyngiomas, glomus tumors, or hemangioblastomas. 
    Cranial arteriovenous malformations and cavernous malformations. 
    Trigeminal neuralgia not responsive to medical management. 
    Medically refractory epilepsy. 
    Movement disorders such as Parkinsons disease, essential tremor and other disabling tremors that are 
refractory to conventional therapy, where the patient has major system disease or coagulopathy, and the patient is unwilling or unsuited for an invasive surgical procedure. 
    Hypothalamic hamartomas. 
    As a boost treatment for larger cranial or spinal lesions that have been treated initially with external beam 
radiation therapy or surgery (e.g., sarcomas, chondrosarcomas, chordomas, and nasopharyngeal or paranasal 
sinus malignancies). 
     
SBRT will be considered medically reasonable and necessary for the following indications:  
    Primary tumors and tumors metastatic to the lung when the following criteria are met: 
        Early stage primary tumors in medically inoperable patients, OR 
        Recurrent early stage lung cancer in medically inoperable patients3, OR 
        Early stage primary tumors in high operative risk patients, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Primary tumors and tumors metastatic to the liver when the following criteria are met: 
        Primary tumors when the patient is not a surgical candidate, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Primary tumors and tumors metastatic to the kidney when the following criteria are met: 
        Primary tumors when the patient is not a surgical candidate, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Primary tumors and tumors metastatic to the adrenal gland when the following criteria are met: 
        Primary tumors when the patient is not a surgical candidate, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Primary tumors and tumors metastatic to the pancreas when the following criteria are met: 
        Primary tumors when the patient is not a surgical candidate, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Pelvic and head and neck tumors that have recurred after primary irradiation when the following criteria are 
met: 
        The patients general medical condition (namely, the performance status) justifies aggressive, curative 
treatment to a primary, non-metastatic cancer, OR 
        Metastatic disease requiring palliation cannot be treated by conventional methods due to proximity of 
adjacent prior irradiated volumes and other measures are not appropriate or safe for the particular patient, OR 
        The patients general medical condition (namely, the performance status) justifies aggressive local therapy 
to one or more deposits of metastatic cancer in an effort either to achieve total disease clearance in the setting 
of oligometastatic disease or to reduce the patients overall burden of systemic disease for a specifically 
defined clinical benefit, AND 
        The targeted tumor(s) can be completed encompassed with acceptable risk to nearby critical normal 
structures. 
    Low to intermediate risk prostate cancer. 
    Bone metastases in the vertebral bodies or the paraspinous region where extra care must be taken to avoid 
excess irradiation of the spinal cord when tumor-ablative doses are administered and when the following 
criteria are met: 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Tumors arising in or near previously irradiated regions when a high level of precision and accuracy is 
required to minimize the risk of injury to surrounding normal tissues. 
    Tumors requiring a high dose per fraction treatment above the level obtainable with other methods of 
radiation therapy. 
 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.