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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 that Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) are 
methods of delivering ionizing radiation using highly focused convergent beams to target a lesion while 
limiting exposure of adjacent structures. Stereotactic describes target lesion localization relative to a known 
three-dimensional reference system that allows for a high degree of anatomic accuracy and precision. Devices 
used for stereotactic guidance may include a body frame with external reference markers in which a patient is 
positioned securely, a system of implanted fiducial markers that can be visualized with low-energy (kV) x-rays, 
and CT-imaging-based systems used to confirm the location of a tumor immediately prior to treatment. 
 
SBRT may be delivered in one to five sessions (fractions). Each fraction requires an identical degree of 
precision, localization and image guidance. SRS is typically performed in a single session, using a rigidly 
attached stereotactic guiding device, other immobilization technology and/or a stereotactic-guidance system. 
 
SRS/SBRT procedures include the following components: 
1. Planning. 
2. Position stabilization (attachment of a frame or frameless) 
3. Imaging for localization (CT, MRI, angiography, PET, etc.) 
4. Computer assisted tumor localization (i.e., Image Guidance) 
5. Treatment planning  number of isocenters, number, placement and length of arcs or angles, number of 
beams, beam size and weight, etc. 
6. Isodose distributions, dosage prescription and calculation 
7. Setup and accuracy verification testing 
8. Simulation of prescribed arcs or fixed portals 
9. Radiation treatment delivery 
 
 
 
 
 
  
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 irridation. 
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. 
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 this information in the Local Coverage Determination (LCD): 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.