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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 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. 
 
SBRT Treatment Planning: 
Treatment planning for SBRT generally follows the same process and procedures as IMRT and 3-D conformal 
therapy plans. As with either treatment planning methods, SBRT planning determines the field size(s), gantry 
angles and other beam characteristics to achieve the desired radiation dose distribution. SBRT plans are highly 
customized to the target volume(s) and may be geometrically more accurate than conventionally fractionated 
external beam treatment plans.  
    Imaging  3-D image acquisition of the target region by simulation is an essential prerequisite to SBRT 
treatment planning. In general, a CT scan of the target region is performed and serves as the baseline image set 
used for dose calculations and, for selected cases, for coregistration of MRI or PET images sets to better define 
the target and surrounding anatomy. If respiratory or other normal organ motion is expected to produce 
significant movement of the target region during radiation therapy delivery, the radiation oncologist may 
additionally elect to order multiphasic treatment planning image sets to account for motion when rendering 
target volumes. Some SBRT treatment systems such as automated robotic delivery may not require multiphasic 
imaging but is still able to deliver breathing-corrected treatment.     Contouring - defining the target and avoidance structures is a multi-step process 
        The radiation oncologist reviews the 3-D images and outlines the treatment target on each slice of the 
image set. The summation of these contours defines the GVT. For multiple image sets, the physician may 
outline separate GTVs on each image set to account for the effect of normal organ motion upon target location 
and shape. Some patients may not have GTVs if they have had previous treatment with surgery or 
chemotherapy, in which case treatment planning will be based on CTVs. 
        The radiation oncologist draws a margin around the GTV to generate a CVT, which encompasses the 
areas at risk for microscopic disease (i.e., not visible on imaging studies). Other CTVs may be created based on 
the estimated volume of residual disease. For multiple image sets, the physician may draw this margin around 
an aggregate volume containing all image set GTVs to generate an organ-motion CTV, or Internal Target 
Volume (ITV). 
        To account for potential daily patient setup variation and/or organ and patient motion, a final margin is 
then added to create a PTV. 
        Nearby normal structures that could potentially be harmed by radiation (i.e., organs at risk or OARs) are 
also contoured. 
    Radiation dose prescribing - The radiation oncologist assigns specific dose requirements for the PTV, which 
typically includes a prescribed dose that must be given to at least 90 to 95 percent of the PTV. Additionally, 
PTV dose requirements routinely include dose constraints for the OARs (e.g., upper limit of mean dose, 
maximum allowable point dose and/or a critical volume of the OAR that must not receive a dose above a 
specified limit). A treatment plan that satisfies these requirements and constraints should maximize the 
potential for disease control and minimize the risk of radiation injury to normal tissue. 
    Dosimetric planning, calculations and dose verification - The medical physicist or a supervised dosimetrist 
calculates a multiple static beam and/or modulated arc treatment plan to deliver the prescribed radiation dose to 
the PTV and simultaneously satisfy the normal tissue dose constraints by delivering significantly lower doses 
to nearby organs. Dose-volume histograms are prepared for the PTV and OARs. Here, an arc is defined as a 
discrete complete or partial rotation of the linear accelerator gantry during which there is continuous motion of 
the MLC to deliver an optimized radiation dose distribution within the patient. The calculated beams or arcs are 
then delivered either to a phantom or a dosimetry measuring device to confirm that the intended dose 
distribution for the patient is physically verifiable and that the beams or arcs are technically feasible. 
 
SBRT Treatment Delivery: 
 
Treatment of extra-cranial sites requires accounting for internal organ motion as well as for patient motion. 
Thus, reliable immobilization or repositioning systems must often be combined with devices capable of 
decreasing organ motion or accounting for organ motion  e.g., use of respiratory gating or robotic target 
tracking for target sites in the chest or upper abdomen. Additionally, all SBRT is performed with at least one 
form of image guidance to confirm proper patient positioning and tumor localization prior to delivery of each 
fraction. SBRT may be delivered in one to five sessions (fractions). Each fraction requires an identical degree 
of precision, localization and image guidance. 
 
SBRT may be used as an alternative to surgery for treating various lesions and may be an effective and safer 
alternative than conventional radiation therapy for certain presentations of cancers and other non-cancer targets. 
Direct physician involvement, image guidance and immobilization are integral to stereotactic treatment for 
these diverse body sites. The medical physicist should perform a second check calculation before initiating the 
first treatment to ensure the monitor units used to deliver the planned treatment are correct. With a radiation 
oncologist, the medical physicist should ensure all of the treatment parameters are correct, including image 
guidance, respiratory motion compensation or any other complex positioning aids that may be employed to 
accurately treat the patient.  
 
SBRT will be considered medically reasonable and necessary for the following indications:  
 
    Primary tumors and tumors metastatic to the lung when the following criteria are met:         Early stage primary tumors in medically inoperable patients, OR 
        Recurrent early stage lung cancer in medically inoperable patients, OR 
        Early stage primary tumors in high operative risk patients, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Primary tumors and tumors metastatic to the liver when the following criteria are met: 
        Primary tumors when the patient is not a surgical candidate, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Primary tumors and tumors metastatic to the kidney when the following criteria are met: 
        Primary tumors when the patient is not a surgical candidate, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Primary tumors and tumors metastatic to the adrenal gland when the following criteria are met: 
        Primary tumors when the patient is not a surgical candidate, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Primary tumors and tumors metastatic to the pancreas when the following criteria are met: 
        Primary tumors when the patient is not a surgical candidate, OR 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Pelvic and head and neck tumors that have recurred after primary irradiation when the following criteria are 
met: 
        The patients general medical condition (namely, the performance status) justifies aggressive, curative 
treatment to a primary, non-metastatic cancer, OR 
        Metastatic disease requiring palliation cannot be treated by conventional methods due to proximity of 
adjacent prior irradiated volumes and other measures are not appropriate or safe for the particular patient, OR 
        The patients general medical condition (namely, the performance status) justifies aggressive local therapy 
to one or more deposits of metastatic cancer in an effort either to achieve total disease clearance in the setting 
of oligometastatic disease or to reduce the patients overall burden of systemic disease for a specifically 
defined clinical benefit, AND 
        The targeted tumor(s) can be completed encompassed with acceptable risk to nearby critical normal 
structures. 
    Low to intermediate risk prostate cancer. 
    Bone metastases in the vertebral bodies or the paraspinous region where extra care must be taken to avoid 
excess irradiation of the spinal cord when tumor-ablative doses are administered and when the following 
criteria are met: 
        Limited metastatic disease, good performance status, and the intention is eradicating all known active 
disease or greatly reducing the total disease burden in a manner that can extend progression-free survival. 
    Tumors arising in or near previously irradiated regions when a high level of precision and accuracy is 
required to minimize the risk of injury to surrounding normal tissues. 
    Tumors requiring a high dose per fraction treatment above the level obtainable with other methods of 
radiation therapy. 
 
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:  
 
    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. 
    SBRT is meant to represent a complete course of treatment and not be used as a boost following a 
conventionally fractionated course of treatment. 
    Treatment is unlikely to result in clinical cancer control and/or functional improvement. 
    The tumor burden cannot be completely targeted with acceptable risk to nearby critical normal structures.  
    Patients with poor performance status (Karnofsky Performance Status less than 40 or ECOG Status of 3 or 
worse). Please refer to additional information below for further scoring information regarding Karnofsky 
Performance Status and ECOG Status. 
 
You can find these rules 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.