Medicare Advantage Medical Policy Updates 10012024

Medical Policy: Medicare Advantage M.7 Gender Reassignment Surgery

Effective Date: 01/01/2025
Preauthorization Required: Yes

Policy Statement:

1. For individuals undergoing sex reassignment surgery, consisting of any combination of the following: hysterectomy, salpingo-oophorectomy, oophorectomy, or orchiectomy, it is considered medically necessary when all of the following criteria are met:
   
   1. The individual is at least 19 years of age; AND
   2. The individual has capacity to make fully informed decisions and consent for treatment; AND
   3. The individual has been diagnosed with gender dysphoria, and exhibits all the following:
      
      1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and treatment; AND
      2. The transgender identity has been present persistently for at least two years; AND
      3. The disorder is not a symptom of another mental disorder; AND
      4. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND
   4. For individuals without a medical contraindication, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; AND
   5. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; AND
   6. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.
2. For individuals undergoing sex reassignment surgery, consisting of any combination of the following, metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, or placement of testicular prostheses, it is considered medically necessary when all of the following criteria are met:
   
   1. The individual is at least 19 years of age; AND
   2. The individual has capacity to make fully informed decisions and consent for treatment; AND
   3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:
      
      1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; AND
      2. The transgender identity has been present persistently for at least two years; AND
      3. The disorder is not a symptom of another mental disorder; AND
      4. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND
   4. For individuals without a medical contraindication, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; AND
   5. Documentation** that the individual has completed a minimum of 12 months of successful continuous full-time real-life experience in their new gender, across a wide range of life experiences and events that may occur throughout the year (for example, family events, holidays, vacations, season specific work or school experiences). This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings); AND
   6. Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; AND
   7. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; AND
   8. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.
      Verification via communication with individuals who have related to the individual in an identity congruent gender role, or requesting documentation of a legal name change, may be reasonable in some cases.
3. The use of hair removal procedures to treat tissue donor sites for a planned phalloplasty or vaginoplasty procedure is considered medically necessary.
4. Mastectomy or breast reduction for transmasculine may be considered medically necessary when ALL of the following criteria are met:
   
   1. For individuals undergoing sex reassignment surgery, bilateral mastectomy or breast reduction is considered medically necessary when ALL of the following criteria have been met:
      
      1. The individual is at least 19 years of age; AND
      2. The individual has capacity to make fully informed decisions and consent for treatment; AND
      3. The individual has been diagnosed with gender dysphoria and exhibits all the following:
         
         1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone
            treatment; AND
         2. The transgender identity has been present persistently for at least two years; AND
         3. The member has a consistent, stable gender identity that is well documented by their treating providers, and when possible, lives as their affirmed gender in places where it is safe to do so; AND
         4. The disorder is not a symptom of another mental disorder; AND
         5. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND
      4. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; AND
      5. Documentation** that the individual has completed a minimum of 12 months of successful continuous full time real life experience in their new gender, across a wide range of life experiences and events that may occur throughout the year (for example, family events, holidays, vacations, season specific work or school experiences). This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings); AND
      6. Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; AND
      7. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.
   2. Breast augmentation for transfeminine members may be considered medically necessary when ALL of the following candidate criteria are met:
      
      1. The individual is at least 19 years of age; AND
      2. The individual has capacity to make fully informed decisions and consent for treatment; AND
      3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:
         
         1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; AND
         2. The transgender identity has been present persistently for at least two years; AND
         3. The member has a consistent, stable gender identity that is well documented by their treating providers, and when possible, lives as their affirmed gender in places where it is safe to do so: AND
         4. The disorder is not a symptom of another mental disorder; AND
         5. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; AND
      4. If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; AND
      5. Documentation** that the individual has completed a minimum of 12 months of successful continuous full-time real-life experience in their new gender, across a wide range of life experiences and events that may occur throughout the year (for example, family events, holidays, vacations, season specific work or school experiences). This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings); AND
      6. Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; AND
      7. Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.
      8. For those candidates without a medical contraindication, the candidate has undergone a minimum of 12 months of continuous hormonal therapy that is provided under the supervision of a licensed clinician without an adequate result for comfort in the social role.

NOTE: Future breast reconstruction surgeries for asymmetry would need to meet medical necessity criteria for reconstruction.

*At least one of the professionals submitting a letter must have a doctoral degree (for example, Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) or a master's level degree in a clinical behavioral science field (for example, M.S.W., L.C.S.W., Nurse Practitioner [N.P.], Advanced Practice Nurse [A.P.R.N.], Licensed Professional Councilor [L.P.C.], and Marriage and Family Therapist [M.F.T.]) and be capable of adequately evaluating comorbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the specifications set forth above.

** The medical documentation should include the start date of living full time in the new gender.

Not Medically Necessary:

Sex reassignment surgery is considered not medically necessary when one or more of the criteria above have not been met.

Cosmetic:

The following procedures are considered cosmetic when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo sex reassignment surgery, including, but not limited to, the following:

• Abdominoplasty
• Blepharoplasty
• Brow lift
• Calf implants
• Electrolysis
• Face lift
• Facial bone reconstruction
• Facial implants
• Gluteal augmentation
• Hair removal/hairplasty, when the criteria above have not been met
• Jaw reduction (jaw contouring)
• Lip reduction/enhancement
• Lipofilling/collagen injections
• Liposuction
• Nose implants
• Pectoral implants
• Rhinoplasty
• Thyroid cartilage reduction (chondroplasty)
• Voice modification surgery
• Voice therapy

Medical Policy: Medicare Advantage M.12 Evolent (Interventional Pain Management and Cervical and Lumbar Spine Surgery

Effective Date: 01/01/2025
Preauthorization Required: Yes

Policy Statement:

Blue Cross and Blue Shield of Nebraska for Medicare Advantage contracts with Evolent for pre- service utilization management for Interventional Pain Management, Cervical Fusion Surgery and Lumbar Spine Surgery. Thoracic surgeries do not require medical review or authorization.

BCBSNE for Medicare Advantage will require prior approvals for these services.

Cervical and Lumbar spine surgery services rendered through the Emergency Room are not managed by Evolent and will not require a pre-service review.

Requirements for the BCBSNE pre-service review include:

• Preauthorization required for coverage. If a pre-service authorization is not completed for these services, the claims for services will be denied as provider liability without opportunity to balance bill the impacted BCBSNE member for the services. However, the claim will be held for review against the criteria to determine if post-discharge services may be eligible for coverage.
• Services will not be covered if criteria are not met. If a pre-service authorization request is submitted and Evolent determines that criteria are not met, benefits are not available. If the BCBSNE Medicare Advantage member chooses to receive the services (and provides written authorization), the claim will deny as member liability. In addition, post-discharge services necessitated by the procedure will also be member liability.
• Submission of the pre-service review.
  • Hours of Operation: 7:00am - 7:00pm (CST) (8:00am-8:00pm EST).
  • Call toll free 1-866-972-9642
  • Website www.RadMD.com

Medical Policy: Medicare Advantage M.13 Radiology

Effective Date: 01/01/2025
Preauthorization Required: Yes

Policy Statement:

Services that require a pre-service review include the following:

• Computed Tomography (CT/CTA)
• Magnetic Resonance Imaging (MRI/MRA)
• Nuclear Cardiology
• Positron Emission Tomography (PET)

NOTE: Plain radiology films, imaging studies performed in conjunction with emergency room services, inpatient hospitalization, urgent care centers, and 23-hour observations are excluded from this requirement.

Medical Policy: Medicare Advantage M.15 Procedures following NCD, LCD Or Interqual Criteria

Effective Date: 01/01/2025
Preauthorization Required: Yes

Policy Statement:

This service codes listed in this policy require a prior authorization for Medicare Advantage.

Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. National coverage determinations (NCDs) and Local coverage determinations are made through an evidence-based process.

BCSNE also uses Interqual^® clinical criteria when a NCD or LCD is not present.

Medical Policy: Medicare Advantage M.19 Intensity Modulated Radiation Therapy (IMRT)

Effective Date: 01/01/2025
Preauthorization Required: Yes

Policy Statement:

1. Intensity Modulated Radiation Therapy (IMRT) may be considered Scientifically Validated for the following:
   
   1. Prostate Cancer
   2. Head and Neck Cancer
      
      1. orbits
      2. sinuses
      3. skull base
      4. aero-digestive tract within the head, neck and salivary glands
      5. supraglottic laryngeal
   3. Central Nervous System lesion
   4. Primary Malignant Gynecologic tumors (cervical, endometrial and vulvar cancers)
   5. Anal Cancer
   6. Patient who requires repeat irradiation of a field which includes the spinal cord when the same region of the spinal cord was exposed to a cumulative dose of greater than 40 Gy during prior irradiation treatment
   7. Lung cancer when the following criteria are met:
      
      1. radiotherapy is being given with curative intent AND
      2. three-dimensional conformal radiotherapy will expose greater than 35% of normal lung tissue to more than a 20-Gy dose volume (V20) AND
      3. IMRT dosimetry demonstrates a reduction in the V20 to at least 10% below the V20 that is achieved with the three-dimensional plan (e.g. from 40% down to 30% or lower) OR
      4. If necessary to get the heart dose below 20Gy and/or to get volume of the heart that gets more than 50Gy under 25%
   8. Abdominal and pelvic cancer (stomach, hepatobiliary tract, pancreas, esophageal cancer) planning and clinical rationale demonstrates superior treatment to 3D CRT
   9. Whole breast irradiation in patients receiving treatment for left sided breast cancer after breast conserving surgery when all of the following are met:
      
      1. significant cardiac radiation exposure cannot be avoided using alternative radiation technique AND
      2. IMRT dosimetry demonstrates significantly reduced cardiac target volume radiation exposure (see guidelines)
   10. Individuals with large breasts when treatment planning with 3D conformal results in hot spots (focal regions with dose variation greater than 10% of target) and the hot spots are able to be avoided using IMRT.
   11. Individuals with recurrent tumors or target tissue that includes the far medial chest wall, internal mammary nodal area, or sternum, with or without intact breast.
2. Intensity Modulated Radiation Therapy (IMRT) is investigational when the above criteria are not met.
3.  Intensity Modulated Radiation Therapy (IMRT) is investigational for all other diagnoses, including but not limited to:
   
   1. Palliative treatment for lung cancer

NOTE: Volumetric modulated arc therapy (VMAT) is a form of IMRT.

Medical Policy: Medicare Advantage M.20 Accelerated Irradiation Therapy, Brachytherapy, and Intraoperative Radiation

Effective Date: 01/01/2025
Preauthorization Required: Yes

Policy Statement:

Brain Tumors

Balloon Brachytherapy in the treatment of primary or recurrent malignant brain tumors or metastasis/es to the brain from primary solid tumors outside the brain is investigative.

Breast Cancer

Accelerated whole breast radiation therapy in the treatment of breast cancer is scientifically validated in patients meeting all of the following criteria:

• Invasive carcinoma of the breast (excluding invasive disease or ductal carcinoma in situ involving the margins of excision); AND
• Tumor < 5 cm in diameter; AND
• Breast width < 25 cm at posterior border of medial and lateral breast tangential beams; AND
• Negative lymph nodes; AND
• Negative surgical margins.

Accelerated partial breast irradiation (APBI), including interstitial APBI, balloon APBI (including Mammosite), or external beam APBI, is Scientifically Validated for the treatment of breast cancer in patients meeting all the following criteria:

• Tumor site is less than or equal to 2cm; AND
• Stage is T1; AND
• Margins are negative (greater or equal to 2mm); AND
• Histology is invasive ductal, invasive lobular or other favorable subtypes; AND
• Pure DCIS is not extensive; AND
• Positive ER receptor.

All uses of accelerated partial breast irradiation using any electronic radiotherapy device to treat breast cancer are investigative.

Accelerated partial-breast irradiation (APBI), including interstitial APBI, balloon APBI, intraoperative APBI, external-beam APBI, and noninvasive brachytherapy using AccuBoost is considered investigational.

All uses of Non-Invasive brachytherapy (AccuBoost) are investigative.

Balloon breast brachytherapy without external beam radiation is investigative:

• When used in patients with stage I or II disease as the sole form of radiotherapy (i.e., accelerated partial breast irradiation) after surgical excision, or
• Local boost irradiation when combined with whole breast radiotherapy but without surgical excision.

All other uses of interstitial or balloon breast brachytherapy are investigative.

Intraoperative Radiation Therapy (IORT) for the treatment of breast cancer is scientifically validated when the following criteria are met:

• Tumor cannot be completely removed, OR
• Tumor has a high risk of recurring in surrounding tissues.
  All other uses of IORT in the treatment of Breast Cancer are investigative.

Colon Cancer

Intraoperative Radiation Therapy (IORT) for the treatment of colon cancer is scientifically validated when the following criteria are met:

• Tumor cannot be completely removed, OR
• Tumor has a high risk of recurring in surrounding tissues.

All other uses of IORT in the treatment of colon cancer is investigational.

Endobronchial Tumors

Endobronchial brachytherapy is scientifically validated in the following clinical situations:

• In patients with primary endobronchial tumors who are not otherwise candidates for surgical resection or external beam radiation therapy due to comorbidities or location of the tumor.
• As palliative therapy in patients with obstructing endobronchial primary or metastatic tumors.

Other applications of endobronchial brachytherapy are investigative including, but not limited to, its use as a radiation "boost" to external beam radiotherapy.

The use of IORT in the treatment of Endobronchial tumors is investigative.

Gynecologic Cancers (Uterine, Cervical, Endometrial)

Brachytherapy is scientifically validated in patients with uterine, cervical or endometrial cancer.

Intraoperative Radiation Therapy (IORT) for the treatment of endometrial cancer is scientifically validated when the following criteria are met:

• Tumor cannot be completely removed, OR
• Tumor has a high risk of recurring in surrounding tissues

All other uses of IORT in the treatment of Gynecologic Cancers are investigative.

Choroid Melanoma

Brachytherapy is Medically Necessary for the indication of Choroid Melanoma.

Nonmelanoma Skin Cancer

Electronic brachytherapy for treatment of nonmelanoma skin cancer is considered investigational.

Prostate Cancer

Radioactive seed implantation alone or as an adjunct to external beam radiation therapy for the treatment of localized non-metastatic (stages AC) prostate cancer is scientifically validated.

All other uses of radioactive seed implantation for prostatic cancer are investigative

The use of IORT in the treatment of Prostate Cancer is investigative.

Rectal Cancer

Use of intraoperative radiation therapy (IORT) in the treatment of rectal cancer is scientifically validated in patient who meet one of the following criteria:

• Positive or close margins with T4 lesions; OR
• Recurrent disease

All other uses of IORT are investigative.

Pancreatic Cancer

Intraoperative Radiation Therapy (IORT) for the treatment of pancreatic cancer is scientifically validated when the following criteria are met:

• Tumor cannot be completely removed, OR
• Tumor has a high risk or recurring in surrounding tissues.

All other uses of IORT in the treatment of Pancreatic Cancers are investigative.

Soft Tissue Sarcoma

Intraoperative Radiation Therapy (IORT) for the treatment of soft tissue sarcoma is considered scientifically validated when the following criteria are met:

• Tumor cannot be completely removed, OR
• Tumor has a high risk of recurring in surrounding tissues

All other uses of IORT in the treatment of soft tissue sarcoma are investigational.

Medical Policy: Medicare Advantage M.21 Radioembolization/Selective Radiotherapy (SIRT)

Effective Date: 01/01/2025
Preauthorization Required: Yes

Policy Statement:

1. Radioembolization (SIRT) may be considered medically necessary to treat primary hepatocellular carcinoma that is unresectable and limited to the liver (see Policy Guidelines section).
2. Radioembolization (SIRT) may be considered medically necessary in primary hepatocellular carcinoma as a bridge to liver transplantation.
3. Radioembolization (SIRT) may be considered medically necessary to treat hepatic metastases from neuroendocrine tumors (carcinoid and noncarcinoid) with diffuse and symptomatic disease when systemic therapy has failed to control symptoms.
4. Radioembolization (SIRT) may be considered medically necessary to treat unresectable hepatic metastases from colorectal carcinoma, melanoma (ocular or cutaneous), or breast cancer that are both progressive and diffuse, in patients with liver-dominant disease who are refractory to chemotherapy or are not candidates for chemotherapy or other systemic therapies.
5. Radioembolization (SIRT) may be considered medically necessary to treat primary intrahepatic cholangiocarcinoma in patients with unresectable tumors.
6. Radioembolization (SIRT) is considered investigational for all other hepatic metastases except as noted above.
7. Radioembolization (SIRT) is considered investigational for all other indications not described above
8. BCBSNE considers preoperative embolization of bone metastasis of Renal Cell Carcinoma, Thyroid cancer investigational because the effectiveness of this approach has not been established.

Medical Policy: Medicare Advantage M.22 Charged Particle Radiation, Helium Ion or Proton, and Stereotactic Radiosurgery (SRS), Stereotactic Radiotherapy (SRT), and Stereotactic Body Radiation (SBRT)

Effective Date: 01/01/2025
Preauthorization Required: Yes

Policy Statement:

1. Stereotactic radiosurgery (SRS) using a gamma knife, cyberknife, or Linac (linear accelerator) may be considered scientifically validated for ANY of the following indications:
   
   1. acoustic neuroma (vestibular schwannomas) OR
   2. arteriovenous malformations OR
   3. craniopharyngioma OR
   4. glomus jugulare tumors (hypervascular tumor that arises within the jugular foramen of the temporal bone) OR
   5. malignancies of the CNS (gliomas, astrocyomas) OR
   6. solitary or multiple brain metastases, in patients with a good performance status and no systemic disease (Karnofsky performance
      scale of at least 70) and extracranial disease that is stable or in remission OR
   7. meningiomas that are nonresectable, residual, or recurrent OR
   8. pituitary adenoma OR
   9. trigeminal neuralgia that is refractory to medical management OR
   10. mesial temporal lobe epilepsy refractory to medical management when standard alternative surgery is not an option OR
   11. uveal melanoma
2. All other indications for stereotactic radiosurgery (SRS) using a gamma knife, cyberknife, or Linac (linear accelerator) are considered Investigational.
3. Stereotactic Body Radiotherapy (SBRT) / Stereotactic Ablative Body Radiotherapy (SARB) may be considered scientifically validated for ANY of the following indications:
   
   1. non-small cell lung cancer, Stage 1, in patients who are not candidates for surgery for who refuse surgery after informed consent.
   2. non-small cell lung cancer, with oligometastasis, i.e. 1-3 metastatic lesions, when ALL of the following are met:
      
      1. definitive RT to the oligometastasis is planned AND
      2. radical therapy to the intrathoracic disease is planned or has been received AND
      3. metastatic sites are in the lung and/or adrenal gland AND
      4. patient has good performance status i.e. Karnofsky performance status (KPS) of at least 70
   3. oligometastasis to the lung from a cancer of unknown primary (NCCN also refers to this as occult primary), when ALL of the following are met:
      
      1. 1-3 metastatic lesions are present in the lungs AND
      2. patient has good performance status i.e. Karnofsky performance status (KPS) is at least 70
   4. spinal tumors, primary- that cause intractable pain or spinal cord compression
   5. spinal tumors, primary or metastatic - in patients who have received previous radiotherapy (RT)
   6. spinal tumors, metastatic- that are radio-resistant e.g. renal cell cancer, melanoma, sarcoma
   7. primary or metastatic tumors of the liver as an alternative locoregional treatment for patients with inoperable primary or metastatic lesions.
   8. primary renal cell carcinoma in patients who are not good surgical candidates or for metastatic renal carcinoma
   9. pancreatic cancer without invasion of bowel or stomach
   10. prostate cancer when ALL the following are met:
       
       1. low grade prostate cancer with a Gleason score of less than or equal to 6 and a PSA less than 10 ng/ml AND
       2. minimal disease with less than four cores positive, AND
       3. no evidence of extra prostatic disease AND
       4. life expectancy is greater than 10 years
   11. oligometastatic prostate cancer with 1-3 metastatic lesions
   12. oligometastatic breast cancer with 1-3 metastatic lesions
4. All other indications for Stereotactic Body Radiotherapy (SBRT)/ Stereotactic Ablative Body Radiotherapy (SABR) are considered Investigational.
5. Fractionation is considered medically necessary when it is used to deliver stereotactic radiosurgery (SRS) or stereotactic body radiation (SBRT) for the medically necessary indications described above.
6. Charged-particle irradiation with proton or helium ion beams may be considered scientifically validated for ANY of the following indications:
   
   1. melanoma of the uveal tract (iris, choroid, or ciliary body) with no evidence of extrascleral extension or metastasis OR
   2. chordomas or chondrosarcomas arising at the base of the skull or cervical spine without distant metastases OR
   3. pediatric central nervous system tumors.
7. All other indications for Charged-particle irradiation with proton or helium ion beams are considered Investigational.