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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. 
 
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.  
 
Indications for Stereotactic Body Radiation Therapy (SBRT): 
 
    SBRT is indicated for primary tumors and tumors metastatic to the lung, liver, kidney, adrenal gland, or 
pancreas. 
    SBRT is indicated for treatment of pelvic and head and neck tumors that have recurred after primary 
irradiation. 
    SBRT is indicated for patients with clinically localized, low- to intermediate-risk prostate cancer. 
    SBRT treatment, of any body site or internal organ, is indicated for treatment of recurrence in or near 
previously irradiated regions when a high level of precision and accuracy or a high dose per fraction is 
indicated to minimize the risk of injury to surrounding normal tissues and treatment with conventional methods 
is not appropriate or safe for the particular patient (medical records must describe the specific circumstances, 
see documentation requirements in the attached Billing and Coding Article). 
 
 Limitations for Stereotactic Body Radiation Therapy (SBRT): 
    Primary treatment of lesions of bone, breast, uterus, ovary, and other internal organs not listed earlier in this 
LCD as covered is not considered medically necessary. 
    SBRT is not considered medically necessary under the following circumstances for any condition: 
        Treatment is unlikely to result in clinical cancer control and/or functional improvement. 
        The tumor burden cannot be completely targeted with acceptable risk to critical normal structures. 
        The patient has a poor performance status (Karnofsky Performance Status less than 40 or Eastern 
Cooperative Oncology Group (ECOG) Status of 3 or worse). Note that the higher a Karnofsky Performance 
Status is, the better a patient is doing. However, the lower an Eastern Cooperative Oncology Group (ECOG) 
Performance Status is, the better a patient is doing. 
        Recurrent (other than pelvic and head and neck tumors) or metastatic disease could be treated by 
conventional methods (record must describe why other radiation therapy measures are not appropriate or safe 
for the particular patient). 
        Since the goal of SBRT is to maximize the potency of the radiotherapy by completing an entire course of 
treatment within an extremely accelerated time frame, any course of radiation treatment extending beyond five 
fractions is not considered SBRT. SBRT is meant to represent a complete course of treatment and not to be 
used as a boost following a conventionally fractionated course of treatment. 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.