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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 state that the advantages of metabolic imaging have made PET the imaging modality of choice for 
staging, restaging, and therapy monitoring for many oncologic indications, especially in advanced stages. 
However, the more precise anatomic detail offered by diagnostic-quality CT and MRI, especially with the 
added information supplied by contrast enhancement, is often sufficient or even preferable for a number of 
oncologic indications. More precise delineation of tumor extent is often needed for tumor staging and planning 
of interventions. More accurate size measurements are often needed for routine follow-up of therapeutic 
efficacy. In most cases, contrast-enhanced CT is sufficient for such 
determinations, when needed. However, the unique tissue contrast offered by MRI provides additional benefits 
in many cases. A few general considerations, but not those which are applied to the pre-payment of claims, 
include: 
 
-MRI is typically more accurate in evaluation of brain lesions, including known or suspected primary or 
metastatic tumors. 
-MRI is typically more accurate than CT in the evaluation of musculoskeletal neoplasms.4. 
-MRI typically shows greater sensitivity, though lesser specificity, for detection of liver metastases than CT or 
PET, while CT shows greater sensitivity for pulmonary metastases. 
-MRI is often more helpful in delineating extent of tumor in anatomically complex regions (e.g., the skull 
base), in evaluating perineural or paravertebral spread of tumor, in evaluation of specific types of lesions in 
specific organs (e.g., pancreas, salivary gland), and in locoregional staging of breast cancer in suspected cases 
of multifocal or multicentric disease, contralateral lesions, or regional metastases (especially in patients with 
dense breasts). 
-In the above situations, MRI may be used for planning of interventions, as well. 
 
General Frequency Guidance on the Use of Advanced Imaging Modalities (CT/MRI/PET) 
1. It is recommended that, when possible, the ordering physician should select a single imaging modality if that 
modality is most likely to provide the most accurate information for providing the most optimal patient care. 
2.  If the initially selected advanced imaging test does not provide sufficient information for clinical decision-
making, then it is appropriate to select a second imaging modality if, in the opinion of the physician, this will 
likely provide clinically useful information in patient management. In general, multiple such studies should be 
employed successively, when needed, and should only be performed together when both are reasonably 
expected to provide information independently important to patient management. 
3. There are multiple reasons for the longitudinal (e.g., excluding baseline assessment, staging/re-staging) use 
of advanced imaging modalities (e.g., CT, MRI, and PET), such as: Surveillance, whereby the patient is 
assumed to have either no known disease, or stable or clinically insignificant disease: It is not unreasonable to 
expect such surveillance to occur every 6-12 months for an overall duration (e.g., five years) which is 
consistent with the tumor biology of that neoplasm. 
Suspected recurrence/progression (as detailed above), whereby frequency guidance is not applicable to more 
of a timeline approach to management. 
Evaluating response to treatment, when a change in therapy is contemplated: In general, imaging 
should be no more often than after 2 cycles of chemotherapy and/or 6-8 weeks since the prior imaging 
evaluation. 
Finally, there are other applications of advanced imaging, including, but not restricted to, image-directed 
biopsy and radiation therapy treatment planning, where frequency guidance is not applicable. 
 
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.