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 Conditions 
 
    Benign or malignant conditions otherwise not suitable for intensity modulated radiation therapy (IMRT) or 
3- dimensional conformal therapy involving the base of the skull or axial skeleton, including but not limited to 
chordomas and chondrosarcomas. 
    Solid tumors in children up to age 18. 
    Benign or malignant central nervous system tumors to include primary and variant forms of 
medulloblastoma, astrocytoma, glioblastoma, arteriovenous malformations, acoustic neuroma 
craniopharyngioma, benign and atypical meningiomas and pineal gland tumors. 
    Intraocular melanomas 
 
Because many radiological oncologists believe that proton beam therapy is a legitimate treatment option in 
certain circumstances where 3-dimensional conformal or intensity modulated radiation therapy (IMRT) is 
deemed medically necessary, proton beam therapy will be considered as medically reasonable and necessary 
for certain other conditions (i.e., Group #2 of ICD-10-CM Codes that Support Medical Necessity) not listed 
above, as long as the following criteria are met: 
 
Either #1, #2, or #3 must be present and 
 
Either #4 or #5 must be present and 
 
#6 must always be present. 
 
1.  When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with 
other indicated methods 
 
2.  When there is a reason to believe that doses generally thought to be above the level otherwise attainable 
with other methods might improve control rates 
 
3.  In circumstances when the higher levels of precision associated with proton beam therapy as compared to other radiation methods are necessary, i.e., clinically relevant 
 
4.  For the treatment of primary lesions, the intent of treatment must be curative 
 
5.  For the treatment of metastatic lesions, there must be 
 
    the expectation of a long-term benefit (> 2y) that could not have been attained with conventional therapy 
    the expectation of a complete eradication 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 
 
6.  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 Dosimetric 
evidence of reduced normal tissue toxicity and/or improved tumor control must be maintained. 
 
You can find this rule in the Local Coverage Determination (LCD) for Proton Beam Radiotherapy (L33937). 
 
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.