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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 
- Group 2 conditions will be considered medically reasonable and necessary 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 be present 
~ When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the 
tumor with other indicated methods 
~ 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 
~ 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 
~ For the treatment of primary lesions, the intent of treatment must be curative 
~ For the treatment of metastatic lesions, there must be 
a. the expectation of a long-term benefit (greater than 2 years) that could not have been 
attained with conventional therapy b. 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 
~ 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. 
- Group 2 conditions 
~ Malignant lesions of the head and neck when the intent of treatment is to be curative. 
~ Malignant lesions of the Para nasal sinus, and other accessory sinuses 
~ Malignant lesions of the prostate 
~ Malignant advanced stage, non-metastatic tumors of the bladder 
~ Advanced pelvic tumors including malignant lesions of the cervix 
~ Left breast tumors 
~ Pancreatic and adrenal tumors 
~ Skin cancer with perineural/cranial nerve invasion 
~ Unresectable retroperitoneal sarcoma and extremity sarcoma 
~ Cancers of the lung and upper abdominal/peri-diaphragmatic cancers 
~ Malignant lesions of the liver, biliary tract, anal canal and rectum 
 
All other indications are not considered reasonable and necessary and will be denied. You can find these rules 
in Local Coverage Determination (LCD) 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.