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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 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). 
 
The rules say Covered Indications: 
 
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 
 
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) not listed 
above, 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. 
 
If the above provisions are met and the patient is treated in a protocol that is designed for evidence 
development and for future publication, it is expected that future published data will support an outcome 
advantage for patients for continued coverage of the specific diagnosis. The protocol in and by itself does not 
constitute criteria for coverage. The presence of an Institutional Review Board review, when appropriate, and 
patient informed consent are also expected. 
 
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  
 
Limitations 
 
In general, proton beam radiotherapy is not indicated for cancers that are widely disseminated, such as 
leukemias, have hematogenous metastases or as a short-term palliative procedure. The intent of treatment 
should be curative. If proton beam radiotherapy is used for a patient with metastatic disease, evidence should 
be provided to justify the expectation of a long-term benefit (> 2y), as well as evidence of a dosimetric 
advantage for proton beam radiotherapy over other forms of radiation therapy. 
 
All other indications are not considered reasonable and necessary and will be denied. 
 
As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 
13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the 
Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under 
which the item or service is considered reasonable and necessary. 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.