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 Appeal Number is:
1-10625463706
The Appeal Number is:
1-10625463706
The rules state that the following are indications for Stereotactic radiosurgery (SRS)/ Stereotactic Body
Radiation Therapy (SBRT) (for Cranial and Spinal Lesions):
1. Primary central nervous system malignancies, generally used as a boost or salvage therapy for lesions <
5 cm.
2. Primary and secondary tumors involving the brain or spine parenchyma, meninges/dura, or immediately
adjacent bony structures.
3. Benign brain tumors and spinal tumors such as meningiomas, acoustic neuromas, other schwannomas,
pituitary adenomas, pineocytomas, craniopharyngiomas, glomus tumors, hemangioblastomas.
4. Cranial arteriovenous malformations, cavernous malformations, and hemangiomas
5. Other cranial non-neoplastic conditions such as trigeminal neuralgia and select cases of medically
refractory epilepsy. As a boost treatment for larger cranial or spinal lesions that have been treated
initially with external beam radiation therapy or surgery (e.g. sarcomas, chondrosarcomas, chordomas,
and nasopharyngeal or paranasal sinus malignancies).
6. Metastatic brain or spine lesions, with stable systemic disease, Karnofsky Performance Status 40 or
greater (or expected to return to 70 or greater with treatment), and otherwise reasonable survival
expectations, OR an Eastern Cooperative Oncology Group (ECOG) Performance Status of 3 or less (or
expected to return to 2 or less with treatment). Note that the higher a Karnofsky Performance Status is,
the better a patient is doing. However, the lower an Eastern Cooperative Oncology Group (ECOG)
Performance Status is, the better a patient is doing.
7. Relapse in a previously irradiated cranial or spinal field where the additional stereotactic precision is
required to avoid unacceptable vital tissue radiation.
8. Choroidal and other ocular melanomas
The following are limitations for SRS/SBRT (for Cranial and Spinal Lesions):
SRS is not considered medically necessary under the following circumstances:
SRS is not considered medically necessary under the following circumstances:
1. Treatment for anything other than a severe symptom or serious threat to life or critical functions.
2. Treatment unlikely to result in functional improvement or clinically meaningful disease stabilization,
not otherwise achievable.
3. Patients with wide-spread cerebral or extra-cranial metastases with limited life expectancy unlikely to
gain clinical benefit within their remaining life.
4. Patients with poor performance status (Karnofsky Performance Status less than 40 or an ECOG
Performance greater than 3) - see Karnofsky and ECOG Performance Status scales below. Note that the
higher a Karnofsky Performance Status is, the better a patient is doing. However, the lower an Eastern
Cooperative Oncology Group (ECOG) Performance Status is, the better a patient is doing.
5. Cobalt-60 pallidotomy is non-covered.
The following are indications for Stereotactic Body Radiation Therapy (SBRT):
1. SBRT is indicated for primary tumors and tumors metastatic to the lung, liver, kidney, adrenal gland, or
pancreas.
2. SBRT is indicated for treatment of pelvic and head and neck tumors that have recurred after primary
irradiation.
3. SBRT is indicated for patients with clinically localized, low- to intermediate-risk prostate cancer.
4. SBRT treatment, of any body site or internal organ, is indicated for treatment of recurrence in or near
previously irradiated regions when a high level of precision and accuracy or a high dose per fraction is
indicated to minimize the risk of injury to surrounding normal tissues and treatment with conventional
methods is not appropriate or safe for the particular patient (medical records must describe the specific
circumstances, see documentation requirements in the attached Billing and Coding Article).
The following are limitations for Stereotactic Body Radiation Therapy (SBRT):
1. Primary treatment of lesions of bone, breast, uterus, ovary, and other internal organs not listed earlier in
this LCD as covered is not considered medically necessary.
2. SBRT is not considered medically necessary under the following circumstances for any condition:
a. Treatment is unlikely to result in clinical cancer control and/or functional improvement.
b. The tumor burden cannot be completely targeted with acceptable risk to critical normal
structures.
c. The patient has a poor performance status (Karnofsky Performance Status less than 40 or
Eastern Cooperative Oncology Group (ECOG) Status of 3 or worse). Note that the higher a
Karnofsky Performance Status is, the better a patient is doing. However, the lower an Eastern
Cooperative Oncology Group (ECOG) Performance Status is, the better a patient is doing.
d. Recurrent (other than pelvic and head and neck tumors) or metastatic disease could be treated by
conventional methods (record must describe why other radiation therapy measures are not
appropriate or safe for the particular patient).
e. Since the goal of SBRT is to maximize the potency of the radiotherapy 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. SBRT is meant to represent a
complete course of treatment and not to be used as a boost following a conventionally
fractionated course of treatment.
You can find these rules in the Local Coverage Determination (LCD) for Stereotactic Radiation Therapy:
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT), L35076.
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