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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 say 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) 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 
a. the expectation of a long-term benefit (greater than 2y) 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 
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.  
Proton beam treatment of the following conditions may be considered medically reasonable and necessary only 
if the above criteria are met as specified. 
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  You can find this rule in the Local Coverage Determination (LCD): Proton Beam Radiotherapy (L33937). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
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.