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) and Stereotactic Body Radiation Therapy (SBRT) are 
noninvasive means of administering high-dose radiotherapy to discreet tumor foci in cranial or extracranial 
locations respectively. The two forms of treatment share certain overarching principles, namely, the use of 
image guidance and related treatment delivery technology for escalating the radiation dose to the tumor with as 
little radiation dose to the surrounding tissue as possible. Both methods are achieved with a stereotactic 
procedure during which a target lesion is localized relative to a known three-dimensional (3-D) reference 
system that allows for a high degree of anatomic accuracy. Examples of devices used for SRS and SBRT 
include a rigid head frame attached to a patient, a body frame with external reference markers in which a 
patient is securely positioned, fixed bony landmarks, a system of implanted fiducial markers that can be 
visualized with low-energy X-rays, and computed tomography (CT) imaging-based systems used to confirm 
the location of the tumor immediately prior to treatment. However, notable differences in clinical applications 
have emerged given the vastly different anatomic and clinical consideration between cranial and extracranial 
target lesions. 
 
Stereotactic Body Radiation Therapy (SBRT): is a radiation treatment modality that couples a high degree of 
anatomic targeting accuracy and reproducibility with very high doses of extremely precise, externally 
generated, ionizing radiation. The therapeutic intent of SBRT is to maximize cell-killing effect on the target(s) 
while minimizing radiation-related injury in adjacent normal tissues. SBRT is used to treat extra-cranial sites. 
 
The patient's record must support the necessity and frequency of treatment. Medical records should include not 
only the standard history and physical but also the patient's functional status and a description of their current 
performance status (Karnofsky Performance Status or Eastern Cooperative Oncology Group Performance 
Status). 
 
For SBRT, a radiation oncologist must evaluate the clinical and technical aspects of the treatment and 
document and sign this evaluation as well as the resulting management decision. Clinical record documentation 
of the technical aspects of treatment planning and delivery should include details of the prescribed dose to the 
target and relevant dose-limiting normal structures and the actual dose delivered and dates of treatment 
delivery. 
 
 
 
 The patients record must demonstrate why SBRT 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 conventional radiation therapy, IMRT or 3-dimensional 
conformal radiation. Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control 
must be included.  
 
SBRT is not considered medically reasonable and necessary under the following circumstances:  
 
    1. Since the goal of SBRT is to maximize the potency of the radiation therapy 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 and is not to be billed as such.2 
    2. SBRT is meant to represent a complete course of treatment and not be used as a boost following a 
conventionally fractionated course of treatment.2 
    3. Treatment is unlikely to result in clinical cancer control and/or functional improvement.2 
    4. The tumor burden cannot be completely targeted with acceptable risk to nearby critical normal structures.  
    5. Patients with poor performance status (Karnofsky Performance Status less than 40 or ECOG Status of 3 or 
worse). 
 
You can find this rule in the Local Coverage Determination (LCD) Stereotactic Radiosurgery (SRS) and 
Stereotactic Body Radiation Therapy (SBRT) L33410. 
 
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.