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 say that Stereotactic Radiosurgery (SRS) combines anatomic accuracy and reproducibility with very 
high doses of highly precise, externally generated ionizing radiation to optimally ablate or eradicate the 
target(s) in the head while minimizing collateral damage to adjacent tissues. Stereotactic means a target 
lesion is localized relative to a known 3-dimensional (3D) reference system. Markers might be used on or in the 
body such as seeds, clips, or surface markers. Devices used in SRS for stereotactic guidance could include rigid 
head frames affixed to the patient, fixed bony landmarks, implanted fiducial markers, or mask-based systems. 
Imaging, planning and treatment typically are performed in close temporal proximity. The delivery of a high 
dose of ionizing radiation that conforms to the shape of the lesion mandates an overall accuracy of 
approximately 1 mm. To assure quality of patient care, the procedure involves a multidisciplinary team 
consisting of a neurosurgeon, radiation oncologist, medical physicist, and radiation therapist. For some 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: position stabilization with or without a frame, imaging for 
localization, computer-assisted tumor localization (i.e., image guidance), treatment planning, isodose 
distributions/dose prescription/dose calculation, setup and accuracy verification testing, simulation of 
prescribed arcs or fixed portals, and radiation delivery. 
 
SRS may be considered medically reasonable and necessary for the following indications: 
 
1. Primary central nervous system (CNS) malignancies, generally used as a boost or salvage therapy for lesions 
under 5 centimeters (cm) 
2. As a boost treatment for larger cranial or spinal lesions that have been treated initially with external beam 
radiation therapy (RT) or surgery  
3. Primary and secondary tumors involving the brain parenchyma, meninges/dura, or immediately adjacent 
bony structures. For new brain metastases, the patient must have a documented Karnofsky Performance Status 
(KPS) score > 70% or an Eastern Cooperative Oncology Group (ECOG) status score of 0-2, be absent of 
leptomeningeal metastases, and not have a primary diagnosis of a lymphoma, germ cell tumor or small cell 
carcinoma. 
4. Benign brain tumors such as meningiomas, acoustic neuromas of Grade 3 or less, other schwannomas, 
pituitary adenomas, pineocytomas, craniopharyngiomas, glomus tumors, and hemangioblastomas 
5. Cranial arteriovenous malformations (AVMs) and cavernous malformations 
6. Trigeminal neuralgia, medically refractory epilepsy, severe Parkinsons disease movement disorder, or 
severe and quality of life (QOL) impacting essential tremor that has not been responsive to medical 
management with at least 2 different agents at optimal doses. (The precise therapies, durations offered and 
responses to each therapy must be documented in the medical record.) 
7. Uveal or ocular melanoma 
8. Relapse in a previously irradiated cranial field where the additional stereotactic precision is required to avoid 
unacceptable vital tissue radiation 
 
SRS is not considered reasonable and necessary under the following clinical circumstances: 
* When functional improvement is not expected 
* When directed toward anything other than a severe symptom or serious threat to life or critical functions 
* When clinically meaningful stabilization of the disease is not expected 
* When other treatment could result in equally meaningful functional improvement or clinical stabilization 
* Patients with poor performance status (KPS score < 40 or ECOG score > 3) 
* Patients with widespread cerebral or extra-cranial metastases with limited life expectancy 
You can find these rules in the Local Coverage Determination (LCD) Radiation Therapies L39553. 
 
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.