Medical Policy



Subject: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT)
Document #: THER-RAD.00010 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017

Description/Scope

This document addresses stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT). SRS and SBRT describe the use of focused radiation beams that overlap at intracranial and extracranial targets, thus sparing adjacent tissues from irradiation. The technique differs from conventional radiation therapy, which involves exposing large areas of tissue to relatively broad fields of radiation over a number of sessions. Fractionated stereotactic radiosurgery refers to multiple sessions of SRS over several days.

Note: Please see the following related documents for additional information:

Position Statement

Medically Necessary:

Stereotactic radiosurgery (SRS) is considered medically necessary when used in the treatment of cranial lesions for the following conditions:

Stereotactic radiosurgery (SRS) is considered medically necessary when used in the treatment of:

Stereotactic body radiotherapy (SBRT) is considered medically necessary when used in the treatment of non-small cell lung cancer (NSCLC) when all of the following are met:

Stereotactic body radiotherapy (SBRT) is considered medically necessary when used in the treatment of metastatic cancer in the lung when all of the following criteria are met:

Stereotactic body radiotherapy (SBRT) is considered medically necessary as a palliative treatment for individuals with specific liver-related symptoms due to tumor bulk (for example, pain) from any primary or metastatic hepatic tumor.

Stereotactic body radiotherapy (SBRT) or Stereotactic radiosurgery (SRS) is considered medically necessary for palliative treatment for individuals with spinal metastases.

Stereotactic body radiotherapy (SBRT) is considered medically necessary in individuals who require repeat irradiation of a field that has received prior irradiation.

Stereotactic body radiotherapy (SBRT) is considered medically necessary for prostate cancer when all of the following criteria are met:

SRS and SBRT performed more than one time on a specific site is called fractionated stereotactic radiotherapy and is considered medically necessary for the above approved indications.

Investigational and Not Medically Necessary:

SRS and SBRT are considered investigational and not medically necessary when the medically necessary criteria listed above are not met.

All other uses of SRS and SBRT are considered investigational and not medically necessary including, but not limited to, treatment of:

Rationale

Cranial
Based on the peer-reviewed medical literature, stereotactic radiosurgery is an accepted and effective method for the treatment of cranial applications listed as medically necessary. This procedure has been demonstrated to have an advantage over traditional radiation treatment allowing higher dose delivery while minimizing radiation exposure to the surrounding normal tissue.  

Key issues regarding the role for SRS in treating metastatic disease are the size and number of lesions that can be treated and whether or not SRS should be combined with whole brain irradiation to address lesions that are undetectable with imaging techniques. As part of the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and Joint Tumor Section Multidisciplinary Evidence Based Clinical Practice Parameter Guidelines on Metastatic Brain Tumors, Linskey and colleagues (2010) developed a guideline addressing this role, which offered the following recommendation:

The local control advantage of single-dose SRS for patients with greater than or equal to 4 metastatic brain tumors and a KPS [Karnofsky performance score] greater than or equal to 70% warrants further investigation in the form of an RCT.

Additionally, the guideline considered the status of systemic disease, defined as either stable or in remission.

SRS has also been studied in a wide variety of other cranial applications including the treatment of epilepsy, chronic pain, Parkinson's disease and other movement disorders. For these applications, there is a lack of studies regarding the safety and effectiveness of radiosurgery in comparison with standard therapies.

Spine
Extracranial tumors in the spinal cord have effectively been treated with SBRT. Degen and colleagues (2005) described the results of 51 participants with 72 primary or metastatic spinal cord lesions. Pain was significantly decreased both at 4 weeks (p<0.001) and at 1 year (p=0.002). Quality of life was maintained throughout the study period.

Gerszten and colleagues (2007) studied a cohort of 500 cases of spinal metastases who underwent radiosurgery. Long-term tumor control was demonstrated in 90% of lesions treated with radiosurgery as a primary treatment modality and in 88% of lesions treated for radiographic tumor progression. Long-term pain improvement occurred in 290 of 336 cases (86%). A total of 27 out of 32 cases (84%) with a progressive neurologic deficit before treatment experienced at least some clinical improvement.  

A 2012 phase I/II study by Wang looked at 149 individuals with non-cord-compression spinal metastases who were treated with SBRT. The authors reported on symptom reduction benefit for 6 months post-treatment and clinical benefit for 2 years. The median overall survival time was 23 months following SBRT. Individuals reported a reduction in pain from baseline and 4 weeks post SBRT treatment and between baseline and 6 months post SBRT treatment. There was also a reduction in opioid use from baseline to 3 months and baseline to 6 months following SBRT treatment.

In 2013, the American Society for Radiation Oncology (ASTRO) published a Model Policy that addressed the role of SBRT in the treatment of spinal metastases, stating SBRT has been demonstrated to achieve durable tumor control when treating lesions in 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. However, the document also notes that when palliation is the primary treatment goal "it is generally appropriate to use a less technically complex form of palliative radiotherapy rather than SBRT."

Primary Lung Cancer
Surgical resection is considered the standard treatment of NSCLC but SBRT has been investigated as a treatment of inoperable NSCLC or in those whose clinical status excludes surgery. Comparisons are also being made to SBRT for operable NSCLC.

A 2015 study by Chang and colleagues pooled the overall survival data between two randomized, phase III trials in which SBRT was compared to lobectomy for operable stage I NSCLC. A total of 58 participants were randomized to either SBRT (n=31) or surgery (n=27). At 3 years, the estimated overall survival in the SBRT cohort was 95% (95% confidence interval [CI], 85-100) and 79% in the surgery group, recurrence-free survival was 86% in the SBRT group and 80% in the surgery group. Larger studies with longer follow-up are warranted.

Timmerman and colleagues (2010) reported results of a Phase II North American multicenter study of SBRT for inoperable early stage lung cancer. Forty-four participants with T1 tumors and 11 participants with T2 tumors that were less than 5 cm in diameter were enrolled with a mean follow-up of 34.4 months (range, 4.8-49.9 months). The primary endpoint was 2-year primary tumor control. Secondary endpoints were disease-free survival, radiation toxicity and overall survival. The study design was neither controlled nor comparative due to the fact that the comparator, conventional radiation, provides poor primary tumor control (less than 40%), whereas 80% control with SBRT was achieved in a prior study. Therefore, the tumor control rate was set at 60% to 80%. The 3-year primary tumor control rate was 97.6%. Although the overall survival rate was 55.8%, the 3-year rate of disseminated failure was 22.1%. The authors determined this trial demonstrated successful SBRT is possible with proper facilities and support services and that further studies are necessary that address disseminated failure post treatment as well as effective dosing for central lung and peripheral tumors.

Treatment of Lung Metastases
SBRT has also been investigated as a treatment of lung metastases. Ricardi et al (2012) reported a retrospective analysis of 61 individuals with lung metastases (77 tumors) treated with SBRT. Individuals had 1 to 3 lung metastases with maximum tumor diameter smaller than 50 mm. The primary endpoint was local control. Secondary endpoints were overall survival, cancer-specific survival, progression-free survival, and treatment-related toxicity. Median follow-up time was 20.4 months. At 2 years, local control was 89%, overall survival was 66.5%, cancer-specific survival was 75.4%, and progression-free survival was 32.4%. Median survival time was 42.8 months. Median progression-free survival time was 11.9 months. The group of individuals (n=24) with small single metastasis had a progression-free survival rate of 70% at 1 year and 52.8% at years 2 and 3.

Liver
SBRT has been used to treat both primary and metastatic liver cancer. Two general applications have been investigated: 1) SBRT for tumor control with the goal of improving survival; or 2) SBRT as a palliative therapy for liver-specific symptoms due to tumor bulk (for example, pain).    

Locally ablative therapies such as chemoembolization or radiofrequency ablation are established therapies for the treatment of inoperable primary liver cancer or metastatic disease. The published literature regarding tumor control consists largely of case series and early phase prospective and retrospective studies of small numbers of participants (Hoyer, 2006; Ibarra 2012; Rule, 2011; Tse, 2008). A meta-analysis by Sawrie (2010) reported on the expected toxicity following SBRT treatment of liver metastasis using one to five large fractions. The authors found eight phase I or phase II studies (one was an overlap in a related series) which reported dose-volume constraints for the liver. The studies ranged from using one to five fractions, making comparisons among the studies difficult. Four of the studies reported no acute or delayed liver toxicities. One study reported a death from liver failure 7 weeks after SBRT. One study reported liver fibrosis, portal hypertension, ascites and bleeding from esophageal varices. Another study reported elevations in gamma-glutamyl transpeptidase. Toxicity was reported to be minimal for liver metastases treated with SBRT.

In a 2016 retrospective review by Wahl and colleagues, the authors reported on 161 participants with hepatocellular carcinoma who received radiofrequency ablation compared to 63 participants who received SBRT. For the participants who received radiofrequency ablation, the freedom from local progression was 83.6% at the 1-year follow-up and 80.2% at the 2-year follow-up. In the SBRT cohort, the progression was 97.4% and 83.8% at 1 and 2 years respectively. In terms of tumor sizes, for those tumors smaller than 2 cm, there was no significant difference between radiofrequency ablation and SBRT in freedom from local progression (hazard ratio [HR], 2.50; 95% CI, 0.72 to 8.67; p=0.15), but for tumors 2 cm or larger, radiofrequency ablation was associated with significantly worse freedom from local progression (HR, 3.35; 95% CI, 1.17 to 9.62, p=0.025). In the radiofrequency ablation group, grade 3+ adverse events occurred in 18 participants and included pneumothorax, sepsis, perforation of the duodenum and colon, bleeding and death. There were three grade 3+ adverse events reported in the SBRT group including radiation-induced liver disease, gastrointestinal bleeding, and worsening ascites. The authors note that while both treatment modalities showed improvement for smaller tumors, SBRT may be preferred for tumors greater than 2 cm and prospective, randomized clinical trials are necessary to compare the two treatment modalities.

In contrast, radiation therapy is an established palliative treatment for symptoms related to tumor bulk. SBRT is considered an option in these situations. 

Pancreas
Most individuals with pancreatic cancer have advanced disease at the time of diagnosis and are not candidates for surgery. SBRT has been investigated as alternative treatment in this setting. However, the existing literature consists of uncontrolled trials of small numbers of participants. These studies cannot confirm that SBRT, either alone or in combination with chemotherapy, results in an improvement in the relevant outcome of progression-free survival (Hoyer, 2005; Koong, 2005; Mahadevan, 2011).

Prostate
External beam radiation therapy is a standard treatment of prostate cancer, and thus there has been interest in SBRT as a technique to increase the radiation dosage while maintaining a comparable or acceptable toxicity profile. In addition, the hypofraction associated with SBRT shortens the treatment time to five visits, compared to the 7 to 9 weeks required for IMRT. This shortened treatment time is an aspect appreciated by individuals. The key outcomes include both tumor control and toxicity, primarily focusing on acute and chronic rectal and genitourinary complications. While there have been no controlled studies directly comparing SBRT and alternative techniques of conformal therapy (for example, IMRT) many prospective case series and retrospective cohort studies of subjects with localized low-risk prostate cancer and prolonged life expectancies have consistently reported that SBRT is associated with an acceptable toxicity profile and tumor control that is comparable to other radiation techniques (Boike, 2011; Freeman, 2011; Katz, 2013; King, 2009; King, 2012; King, 2013a; Madsen, 2007; McBride, 2012; Yu, 2014). The largest study was reported by King and colleagues (2013b) who performed a pooled analysis of 1100 individuals from 8 institutions during 2003-2011 with clinically localized prostate cancer (11% high risk, 58% intermediate risk, 30% low risk) treated with SBRT (median dose of 36.25 Gy in 4-5 fractions). The 5-year biochemical relapse-free survival (bRFS) rate was 93% for all individuals. For 135 individuals possessing a minimum of 5-years follow-up, the 5-year bRFS rate for low- and intermediate-risk participants was 99% and 93%, respectively. The authors concluded that PSA relapse-free survival rates after SBRT compare favorably with other definitive treatments for low- and intermediate-risk individuals and that the current evidence supports consideration of SBRT among the therapeutic options for these individuals. In their retrospective cohort study of Medicare beneficiaries, Yu (2014) reported a higher incidence of urinary toxicity was associated with SBRT compared with IMRT, but also noted that the study design could not establish cause and effect. In addition, the continuous evolution of radiation techniques and dosages are designed to address urinary and rectal complications.  

A study by Katz (2014) reported on the 7-year outcomes for individuals with low- to intermediate-risk prostate cancer who received SBRT. A total of 477 men were included in the study. All of the men had biopsy-proven, newly diagnosed non-metastatic prostate cancer. Fifteen of the men were treated prospectively to assess the feasibility of the approach. The rest of the participants were treated to the approved protocol, but not in a prospective fashion. Their outcomes were incorporated as a retrospective study. Only low-risk (n=324) and intermediate-risk participants (n=153) were included. For this study, low risk was defined as PSA less than 10 ng/mL and Gleason less than 7. Intermediate risk was defined as PSA 10-20 ng/mL or Gleason equal to 7. With a median follow-up of 72 months, the biochemical disease-free survival rate was 93.7% for all participants. For low risk it was 95.9% and for intermediate risk it was 89.3%. The overall median PSA at 7 years was 0.11 ng/mL. There was no grade 3-4 acute genitourinary or gastrointestinal toxicity. Nine participants had late grade 3 genitourinary toxicity.

In a 2015 study by Freeman and colleagues, the authors reported on the safety and efficacy of SBRT of the prostate in individuals with clinically localized prostate cancer. In this registry data study, over 2000 men were enrolled and all received radiosurgery at least once in their treatment of prostate cancer. A total of 86% of the participants were treated with SBRT as monotherapy and 8% received radiotherapy as a boost following external beam radiation. For the entire study cohort, the 2-year biochemical disease-free survival rate was 92%, 99% for the low-risk group, 97% for the intermediate-risk group with Gleason 3 + 4, 85% for the intermediate-risk group with Gleason 4 + 3, and 87% for the high-risk group. There were no grade 3 late urinary toxicities noted and there was 1 participant who reported a grade 3 gastrointestinal toxicity (rectal bleeding).

In May, 2013, ASTRO updated its Model Policy for SBRT and states "It is ASTRO's opinion that data supporting the use of SBRT for prostate cancer have matured to a point where SBRT could be considered an appropriate alternative for select patients with low to intermediate risk disease." The 2017 National Comprehensive Cancer Network® Clinical Practice Guidelines (NCCN Guidelines® ) for the treatment of prostate cancer note that SBRT is an emerging treatment modality and can be considered cautiously as an alternative to conventionally fractionated regimens.

Renal
The available published data are small studies addressing tumor burden, local control and dosing. These small studies fail to establish a role of SBRT in the treatment of renal cancer.

Svedman and colleagues (2006) reported the results of a prospective study evaluating the safety and local efficacy of SBRT in metastatic or inoperable primary renal cancer. Thirty participants with metastatic renal cell carcinoma or inoperable primary renal cell carcinoma received high-dose fraction SBRT. In total, 82 lesions were treated. Dose/fractionation schedules varied depending on target location and size. Local control, defined as radiologically stable disease or partial/complete response was obtained in 98% of treated lesions, but 19% of lesions were in those with a follow-up time of less than 6 months. Complete response was observed in 21% of the participants and 58% of this group had a partial volume reduction or local stable disease after a median follow-up of 52 months (range 11-66) for individuals alive and 18 months (range 4-57) for deceased individuals. Local progression was seen in two lesions. Side effects were grade I-II in 90% of cases. The overall survival was 32 months. The authors concluded that this method can be considered a therapeutic option to surgery in those with a limited number of metastases, as local treatment in renal cell carcinoma with an indolent presentation or as a method of reducing tumor burden prior to medical treatment. To be considered as an option to surgery, studies are needed comparing outcomes of this treatment with the established treatment which is surgery.

Beitler and colleagues (2004) studied 9 individuals with non-metastatic renal cell carcinomas. In this group, 2 had bilateral renal cell cancer. Participants were treated definitively with 40 Gy in 5 fractions using conformal external radiation. The median follow up was 26.7 months. Four of the 9 individuals were alive and had a minimum follow-up of 48 months. The authors reported that all 4 of the survivors had tumors that were less than or equal to 3.4 cm in largest dimension with clinically negative nodes. The authors concluded that high-dose-per-fraction, conformal external radiation may have a curative role for small, node-negative, organ-confined renal cell carcinomas.

Accelerated Partial Breast Irradiation
In recent years there has been interest in using SBRT for accelerated partial breast irradiation as opposed to whole breast radiation therapy. In a 2014 study by Vermeulen and colleagues, 41 participants at two separate hospitals (n=21 at hospital #1 and n=26 at hospital #2) with early-stage breast cancer were treated with SBRT. The participants were older than 45 years of age, had Tis, T0, T1, T2 non-lobular carcinomas less than 3 cm, with negative margins (>2 mm) and lymph nodes. The accelerated partial breast irradiation was initiated within 9 weeks of the last breast cancer surgery. The SBRT fractions were either 5 Gy or 10 Gy. Treatment was performed twice a day and completed within 2 weeks. Follow-up ranged from 6-57 months with a mean of 31 months. No breast cancer recurrence had been identified. At hospital #1, 2 participants reported minimal erythema involving a small portion of the breast and half of the participants reported minimal fatigue. There was no treatment for the two toxicities and they subsided by 2 and 3 weeks respectively. One participant had minor pain at the lumpectomy site at 10 months, one participant had palpable non-painful firmness at the lumpectomy site but the shape of the breast was excellent with minimal skin fibrosis. The size, shape and texture of the treated breast was compared to the breast's original appearance after surgery and from pictures taken at the time of simulation, cosmetic outcome was reported as excellent or good in all 21 participants. At hospital #2, there was a follow-up range of 7-39 months with a mean of 21 months. All 26 participants remained locally controlled with no evidence of disease following treatment. One participant had grade 1 dry skin desquamation. Using the Harvard cosmesis scale, 25 participants had good to excellent cosmesis.

In another study by Obayomi-Davies and colleagues (2016), 21 participants received CyberKnife stereotactic accelerated partial breast irradiation. All participants had node negative early stage breast cancer. All participants received 30 Gy in five fractions. Cosmesis was assessed using the Harvard Breast Cosmesis Scale. Twenty participants were successfully treated. Median follow-up was 18 months. No recurrences have recurred. Two participants experienced grade I localized dermatitis at 4 weeks. Cosmesis was good-excellent in all participants.

While the interest of SBRT for accelerated partial breast irradiation continues, there is a lack of sufficient data for SBRT to be established as an approach for accelerated partial breast irradiation due to small participant groups, observational studies, and case series. Further research is necessary.

Gamma Knife Thalamotomy for Tremor
In a case series, Kondziolka and colleagues (2008) studied 26 individuals with medically refractory essential tremor (ET) who were not considered appropriate candidates for invasive thalamotomy. The participants were treated with SRS using Gamma Knife thalamotomy (GKT). Outcomes at 36 months showed that the mean tremor score (± standard deviation) was 3.7 ± 0.1 preoperatively and 1.7 ± 0.3 after radiosurgery (p<0.000015). The authors propose that GKT is an effective therapy for medically refractory essential tremor but that future research should include controlled, prospective trials to delineate the optimum parameters for GKT (for example, participant selection, radiosurgical dose, dose rate) and to determine the safety and efficacy of GKT as compared with other modalities.

Ohye and colleagues (2012) reported on the use of GKT for intractable tremor. A total of 72 participants with refractory tremor of Parkinson's disease or ET were included. All participants received a standard dose of 130 Gy and were followed for 24 months. Fifty-three individuals were available for final follow-up evaluation. There were 43/53 individuals who were categorized as excellent or good, 8/53 categorized as no change, 2/53 were categorized as worse. Further studies are needed to compare the efficacy between GKT and other ventralis intermedius surgeries.

The American Academy of Neurology (AAN,2011), Evidence-based guideline update: Treatment of essential tremor: Report of the Quality Standards Subcommittee concluded that there is insufficient evidence to make recommendations regarding the use of GKT in the treatment of ET.

Currently, the National Institutes of Health (NIH) are conducting clinical trials studying SBRT for the above applications. Areas of study include dose escalation, toxicity, tumor control/evaluation and survival.

Reirradiation
The 2013 ASTRO Model Policy for SBRT states that individuals who have tumors arising in or near areas that have been previously irradiated may be appropriate for SBRT treatment, stating SBRT may be appropriate when a high level of precision and accuracy is needed to minimize the risk of injury to surrounding normal tissues.

Background/Overview

SRS and SBRT are image-guided radiation therapies delivered with precisely to well-defined target volumes. SRS and SBRT differ from traditional surgery in that radiosurgery is noninvasive because it does not remove the tumor or lesion. Instead, it destroys tumor cells or stops the growth of active tissue. The selection of radiosurgery vs. traditional surgery is determined by many factors, including the size, type and location of the tumor, how rapidly symptoms arise, and the overall clinical status of the individual. The potential complications of stereotactic radiosurgery include radiation toxicity, local pain and swelling in the treatment area. Normal tissue adjacent to the target area may be affected.

Prior to the SRS or SBRT procedure, the target area was precisely located and mapped using computed tomography or magnetic resonance imaging. Once the target was localized, different types of radiation sources were used. There are three basic forms of stereotactic radiosurgery represented by three different technological instruments. Each instrument operates differently, has a different source of radiation and may be more effective under different circumstances. The three are:

When a Gamma Knife is used, the individual wears a skeletal frame to immobilize the target area. The frame remains in place and the Gamma Knife device does not move during the procedure insuring that the reference points used in the mapping procedure are not lost. The Gamma Knifeis most frequently used for intracranial lesions.

The Cyberknife system is used primarily for SBRT. This system delivers high dose radiation via a moving gantry. The Cyberknife has to compensate functional body movements such as breathing, heart beat and peristalsis because it does not use frames for immobilization. To accommodate for movement, the Cyberknife incorporates real time imaging and fiduciary placement markers that are used to continually triangulate the geometric position of the target lesion within the body. A microprocessor calculates fiduciary displacement caused by movement and compensates for radiation delivery during the treatment process.

When SRS or SBRT is delivered over a course of days, rather than in a single session, the technique is referred to as fractionated stereotactic radiotherapy. The rationale for fractionation of radiosurgery is the same as that for conventional radiation: It results in the highest "therapeutic ratio" (highest destruction of tumor cells with the lowest effect on normal adjacent tissue and structures). The tumor and the normal tissues respond differently to high single doses vs. multiple smaller doses of radiation. Single large doses can irradiate normal tissue more than several smaller doses. Multiple smaller doses can destroy tumor cells while sparing the normal tissues. However, until recently, fractionation was not possible using stereotactic techniques due to the inability to precisely reposition for tumor target location. Radiosurgery technology has been improved and is now equipped to relocate the target tumor and permit fractionation.

Definitions

Acoustic neuroma: A non-life-threatening tumor that may develop on the nerves near the inner ear controlling hearing and balance.

Adenoma: A benign (non-cancerous) tumor made up of cells that form glands.

Arteriovenous malformation (AVM): An abnormal vascular structure where an artery is directly connected to a vein without the normally intervening smaller arterioles, capillaries, and veins.

Cyberknife: A specialized linear accelerator system utilizing geometric triangulation of target tissue thus eliminating the need for immobilization frames. This system is used for extracranial targets.

ECOG Performance Status:

Gamma Knife: A device that delivers a focused beam of high-energy particle radiation (gamma particles) used for intracranial targets.

Gliomas:A brain tumor that begins in a glial, or supportive cell, in the brain or spinal cord.

Gray (Gy): The unit measurement for the absorption of one joule of energy, in the form of ionizing radiation, by one kilogram of matter.

Karnofsky performance status scale:

Linear accelerator: A device used to create high energy x-rays for use in radiation therapy.

Meningioma: A common type of slow growing, usually non-life-threatening brain tumor that arises from the membranes covering the brain or spinal cord.

Metastasis: The spread of cancer from one part of the body to another.

Non-small cell lung cancer: A group of lung cancers that are named for the kinds of cells found in the cancer and how the cells look under a microscope. The three main types of non-small cell lung cancer are squamous cell carcinoma, large cell carcinoma, and adenocarcinoma. Non-small cell lung cancer is the most common kind of lung cancer.

Pineal tumor: Pineal tumors arise in the region of the pineal gland. This gland is a small structure deep within the brain. At least 17 different types of tumors may occur in this region, and many are benign. The three most common types of pineal region tumors are: gliomas, germ cell tumors and pineal cell tumors.

Pituitary adenoma: A type of benign glandular tumor that usually remains confined to the pituitary gland; serious health problems may arise from this type of tumor if it becomes too large and compresses or causes damage to nearby parts of the brain, invades or presses on other portions of the pituitary gland causing a deficiency of pituitary hormones, or produces and releases too much of one or more pituitary hormones.

Radiosurgery: A form of radiation therapy, which involves various technologies, to create highly focused beams of radiation to increase the accuracy of treatment.

Stereotactic: Refers to the precise positioning of tumors and other lesions in three-dimensional space which allows for increased accuracy of treatment; for example, radiation therapy can be done stereotactically, as a number of precisely aimed beams of ionizing radiation are aimed from several directions to converge on a tumor.

Stereotactic body radiotherapy (SBRT): A type of external radiation therapy that uses special equipment to position an individual and precisely deliver radiation to tumors in the body.

Stereotactic radiosurgery (SRS): A radiation therapy technique that uses a large number of narrow, precisely aimed, highly focused beams of ionizing radiation. The beams are aimed from many directions and meet at a specific point.

Trigeminal neuralgia (tic douloureux): A nerve disorder that stimulates the fifth cranial (trigeminal) nerve in the face and causes episodes of intense, stabbing, electric shock-like pain where the branches of the nerve are distributed to the lips, eyes, nose, scalp, forehead, upper jaw, or lower jaw.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

SRS Cranial Lesions – specific codes
When services are Medically Necessary:

CPT  
  For the following codes when specified as gamma ray or linear accelerator:
61796 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion
61797 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple
61798 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion
61799 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex
61800 Application of stereotactic headframe for stereotactic radiosurgery
77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based
77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based
77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)
   
ICD-10 Procedure  
D020DZZ- D021JZZ Stereotactic radiosurgery of brain, brain stem, other photon or gamma beam [includes codes D020DZZ, D020JZZ, D021DZZ, D021JZZ]
D820DZZ-D820JZZ Stereotactic radiosurgery of eye, other photon or gamma beam [includes codes D820DZZ, D820JZZ]
D920DZZ-D92DJZZ Stereotactic radiosurgery of ear, nose, mouth and throat, other photon or gamma beam [includes codes D920DZZ, D920JZZ, D921DZZ, D921JZZ, D924DZZ, D924JZZ, D925DZZ, D925JZZ, D926DZZ, D926JZZ, D927DZZ, D927JZZ, D928DZZ, D928JZZ, D929DZZ, D929JZZ, D92BDZZ, D92BJZZ, D92CDZZ, D92CJZZ, D92DDZZ, D92DJZZ]
DG20DZZ-DG21JZZ Stereotactic radiosurgery of pituitary gland or pineal body, other photon or gamma beam [includes codes DG20DZZ, DG20JZZ, DG21DZZ, DG21JZZ]
DW21DZZ-DW21JZZ Stereotactic radiosurgery of head and neck, other photon or gamma beam [includes codes DW21DZZ, DW21JZZ]
   
ICD-10 Diagnosis  
C75.3 Malignant neoplasm of pineal gland
D35.2-D35.4 Benign neoplasm of pituitary gland, craniopharyngeal duct [craniopharyngioma], pineal gland
D44.3 Neoplasm of uncertain behavior of pituitary gland,
D44.4 Neoplasm of uncertain behavior of craniopharyngeal duct [craniopharyngioma]
E22.0 Acromegaly and pituitary gigantism
E24.0-E24.9 Cushing's syndrome
E26.01-E26.9 Hyperaldosteronism
Q28.2 Arteriovenous malformation of cerebral vessels

When services may be Medically Necessary when criteria are met:
For the procedure codes listed above, for the following diagnoses.

ICD-10 Diagnosis  
C69.30-C69.32 Malignant neoplasm of choroid [when specified as uveal melanoma]
C69.40-C69.42 Malignant neoplasm of ciliary body [when specified as uveal melanoma]
C70.0 Malignant neoplasm of cerebral meninges
C71.0-C71.9 Malignant neoplasm of brain
C79.31- C79.32 Secondary malignant neoplasm of brain, cerebral meninges
C79.51 Secondary malignant neoplasm of bone
D32.0 Benign neoplasm of cerebral meninges
D33.3 Benign neoplasm of cranial nerves [specified as acoustic neuroma or  schwannoma]
D36.11 Benign neoplasm of peripheral nerves and autonomic nervous system of face, head, and neck [when specified as schwannoma]
D42.0 Neoplasm of uncertain behavior of cerebral meninges
D43.0-D43.2 Neoplasm of uncertain behavior, brain
D43.3 Neoplasm of uncertain behavior of cranial nerves [specified as acoustic neuroma or  schwannoma]
G50.0 Trigeminal neuralgia
  Or for the following diagnoses codes for non-brain primary malignancies with brain metastases or for repeat irradiation:
C00.0-C75.2 Malignant neoplasms (code range)
C75.4-C75.9 Malignant neoplasms (code range)
C7A.00-C7A.8 Malignant carcinoid tumors
C76.0-C76.8 Malignant neoplasms (code range)
C80.0-C80.2 Malignant neoplasms (code range)

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

SRS Spinal Lesions – specific codes
When services may be Medically Necessary when criteria are met:

CPT  
  For the following codes when specified as gamma ray or linear accelerator:
63620 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator), 1 spinal lesion
63621 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator), each additional spinal lesion
   
ICD-10 Procedure  
D026DZZ Stereotactic other photon radiosurgery of spinal cord
D026JZZ Stereotactic gamma beam radiosurgery of spinal cord
   
ICD-10 Diagnosis  
C70.1 Malignant neoplasm of spinal meninges
C72.0 Malignant neoplasm of spinal cord
C79.49 Secondary malignant neoplasm of other parts of nervous system (spinal cord)
C79.51 Secondary malignant neoplasm of bone
D32.1 Benign neoplasm of spinal meninges
D33.4 Benign neoplasm of spinal cord
D42.1 Neoplasm of uncertain behavior of spinal meninges
D43.4 Neoplasm of uncertain behavior of spinal cord
  Or for the following diagnoses codes for malignancies with spinal metastases
C00.0-C75.9 Malignant neoplasms (code range)
C7A.00-C7A.8 Malignant carcinoid tumors
C76.0-C76.8 Malignant neoplasms (code range)
C80.0-C80.2 Malignant neoplasms (code range)

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

SBRT pulmonary – specific codes
When services may be Medically Necessary when criteria are met:

CPT  
32701 Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment
   
ICD-10 Procedure  
DB21DZZ-DB22DZZ Stereotactic other photon radiosurgery of bronchus, lung [includes codes DB21DZZ, DB22DZZ]
DB21JZZ-DB22JZZ Stereotactic gamma beam radiosurgery of bronchus, lung [includes codes DB21JZZ, DB22JZZ]
   
ICD-10 Diagnosis  
C34.00-C34.92 Malignant neoplasm of bronchus and lung
C78.00-C78.02 Secondary malignant neoplasm of lung
D02.20-D02.22 Carcinoma in situ, bronchus and lung

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

SRS/SBRT –non-specific codes or other than cranial, spinal and pulmonary)
When services are Medically Necessary:

CPT  
77299 Unlisted procedure, therapeutic radiology clinical treatment planning [when specified as stereotactic radiation therapy planning (no specific code for SRS or SBRT treatment planning)]
77301 Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications [when specified as treatment planning for SRS or SBRT]
77338 Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan [when specified as devices for SRS or SBRT]
77373 Stereotactic body radiation therapy, treatment delivery per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services [when specified as related to stereotactic radiation therapy]
77435 Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions
   
HCPCS  
G0339 Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment
G0340 Image-guided robotic linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions; maximum five sessions per course of treatment
   
ICD-10 Procedure  
D027DZZ-D027JZZ Stereotactic radiosurgery, other photon or gamma beam of peripheral nerve [includes codes D027DZZ, D027JZZ]
D720DZZ-D728JZZ Stereotactic radiosurgery, other photon or gamma beam of lymphatic and hematologic system [includes codes D720DZZ, D720JZZ, D721DZZ, D721JZZ, D722DZZ, D722JZZ, D723DZZ, D723JZZ, D724DZZ, D724JZZ, D725DZZ, D725JZZ, D726DZZ, D726JZZ, D727DZZ, D727JZZ, D728DZZ, D728JZZ]
DB20DZZ-DB28JZZ Stereotactic radiosurgery, other photon or gamma beam of trachea, pleura, mediastinum, chest wall, diaphragm [includes codes DB20DZZ, DB20JZZ, DB25DZZ, DB25JZZ, DB26DZZ, DB26JZZ, DB27DZZ, DB27JZZ, DB28DZZ, DB28JZZ]
DD20DZZ-DD27JZZ Stereotactic radiosurgery, other photon or gamma beam of gastrointestinal system [includes codes DD20DZZ, DD20JZZ, DD21DZZ, DD21JZZ, DD22DZZ, DD22JZZ, DD23DZZ, DD23JZZ, DD24DZZ, DD24JZZ, DD25DZZ, DD25JZZ, DD27DZZ, DD27JZZ]
DF20DZZ-DF23JZZ Stereotactic radiosurgery, other photon or gamma beam of hepatobiliary system and pancreas [includes codes DF20DZZ, DF20JZZ, DF21DZZ, DF21JZZ, DF22DZZ, DF22JZZ, DF23DZZ, DF23JZZ]
DG22DZZ-DG25JZZ Stereotactic radiosurgery, other photon or gamma beam of adrenal, parathyroid and thyroid glands [includes codes DG22DZZ, DG22JZZ, DG24DZZ, DG24JZZ, DG25DZZ, DG25JZZ]
DM20DZZ-DM21JZZ Stereotactic radiosurgery, other photon or gamma beam of breast [includes codes DM20DZZ, DM20JZZ, DM21DZZ, DM21JZZ]
DT20DZZ-DT23JZZ Stereotactic radiosurgery, other photon or gamma beam of urinary system [includes codes DT20DZZ, DT20JZZ, DT21DZZ, DT21JZZ, DT22DZZ, DT22JZZ, DT23DZZ, DT23JZZ]
DU20DZZ-DV21JZZ Stereotactic radiosurgery, other photon or gamma beam of female and male reproductive systems [includes codes DU20DZZ, DU20JZZ, DU21DZZ, DU21JZZ, DU22DZZ, DU22JZZ, DV20DZZ, DV20JZZ, DV21DZZ, DV21JZZ]
DW22DZZ-DW26JZZ Stereotactic radiosurgery, other photon or gamma beam by anatomical region [includes codes DW22DZZ, DW22JZZ, DW23DZZ, DW23JZZ, DW26DZZ, DW26JZZ]
   
ICD-10 Diagnosis  
C75.3 Malignant neoplasm of pineal gland
D35.2-D35.4 Benign neoplasm of pituitary gland, craniopharyngeal duct [craniopharyngioma], pineal gland
D44.3 Neoplasm of uncertain behavior of pituitary gland,
D44.4 Neoplasm of uncertain behavior of craniopharyngeal duct [craniopharyngioma]
E22.0 Acromegaly and pituitary gigantism
E24.0-E24.9 Cushing's syndrome
E26.01-E26.9 Hyperaldosteronism
Q28.2 Arteriovenous malformation of cerebral vessels

When services may be Medically Necessary when criteria are met:
For the procedure codes listed above for the following diagnoses

ICD-10 Diagnosis  
C00.0-C75.2 Malignant neoplasms (code range)
C75.4-C75.9 Malignant neoplasms (code range)
C7A.00-C7A.8 Malignant carcinoid tumors
C76.0-C76.8 Malignant neoplasms (code range)
C78.00-C78.02 Secondary malignant neoplasm of lung
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile ducts
C79.31- C79.32 Secondary malignant neoplasm of brain, cerebral meninges
C79.49 Secondary malignant neoplasm of other parts of nervous system (spinal cord)
C79.51 Secondary malignant neoplasm of bone [cranial or spinal]
C80.0-C80.2 Malignant neoplasms (code range)
D02.20-D02.22 Carcinoma in situ, bronchus and lung
D32.0 Benign neoplasm of cerebral meninges
D32.1 Benign neoplasm of spinal meninges
D33.3 Benign neoplasm of cranial nerves [specified as acoustic neuroma or  schwannoma]
D33.4 Benign neoplasm of spinal cord
D36.11 Benign neoplasm of peripheral nerves and autonomic nervous system of face, head, and neck [when specified as schwannoma]
D42.0 Neoplasm of uncertain behavior of cerebral meninges
D42.1 Neoplasm of uncertain behavior of spinal meninges
D43.0-D43.2 Neoplasm of uncertain behavior, brain
D43.3 Neoplasm of uncertain behavior of cranial nerves [specified as acoustic neuroma or  schwannoma]
D43.4 Neoplasm of uncertain behavior of spinal cord
G50.0 Trigeminal neuralgia

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above for all other diagnoses not listed; or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

References

Peer Reviewed Publications:

  1. Aoyama H, Shirato H, Tago M, et al. Stereotactic radiosurgery plus whole-brain radiation therapy vs. stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA. 2006; 295(21):2483-2491.
  2. Beitler JJ, Makara D, Silverman P, Lederman G. Definitive, high-dose-per-fraction, conformal, stereotactic external radiation for renal cell carcinoma. Am J Clin Oncol. 2004; 27(6):646-648.
  3. Boike TP, Lotan Y, Cho LC, et al. Phase I dose-escalation study of stereotactic body radiation therapy for low- and intermediate-risk prostate cancer. J Clin Oncol. 2011; 29(15):2020-2026. 
  4. Brown WT, Wu X, Fayad F, et al. CyberKnife radiosurgery for stage I lung cancer: results at 36 months. Clin Lung Cancer. 2007; 8(8):488-492.
  5. Chang JY, Senan S, Paul MA,et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol. 2015 Jun;16(6):630-637.
  6. Degen JW, Gagnon GJ, Voyadzis JM, et al. CyberKnife stereotactic radiosurgical treatment of spinal tumors for pain control and quality of life. J Neurosurg Spine. 2005; 2(5):540-549.
  7. Epstein JI, Egevad L, Amin MB, et al. The 2014 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma: definition of grading patterns and proposal for a new grading system. Am J Surg Pathol. 2016; 40(2):244-252.
  8. Freeman D, Dickerson G, Perman M et al. Multi-institutional registry for prostate cancer radiosurgery: a prospective observational clinical trial. Front Oncol. 2015; 4:369.
  9. Freeman DE, King CR. Stereotactic body radiotherapy for low-risk prostate cancer: five-year outcomes. Radiat Oncol. 2011; 6(3): 1-5.
  10. Gagnon GJ, Nasr NM, Liao JJ, et al. Treatment of spinal tumors using cyberknife fractionated stereotactic radiosurgery: pain and quality-of-life assessment after treatment in 200 patients. Neurosurgery. 2009; 64(2):297-306.
  11. Gerszten PC, Burton SA, Ozhasoglu C, Welch WC. Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976). 2007; 32(2):193-199.
  12. Gerszten PC, Ozhasoglu C, Burton SA, et al. CyberKnife frameless stereotactic radiosurgery for spinal lesions: clinical experience in 125 cases. Neurosurgery. 2004; 55(1):89-99. 
  13. Hoopes DJ, Tann M, Fletcher JW, et al. FDG-PET and stereotactic body radiotherapy (SBRT) for stage I non-small-cell lung cancer. Lung Cancer. 2007; 56(2):229-234. 
  14. Hoyer M, Roed H, Sengelov L, et al. Phase-II study on stereotactic radiotherapy of locally advanced pancreatic carcinoma. Radiother Oncol. 2005; 76(1):48-53.
  15. Hoyer M, Roed H, Traberg Hansen A, et al. Phase II study on stereotactic body radiotherapy for colorectal metastases. Acta Oncologica 2006; 45(7):823-830.
  16. Ibarra RA, Rojas D, Snyder L, et al. Multicenter results of stereotactic body radiotherapy (SBRT) for non-resectable primary liver tumors. Acta Oncol. 2012; 51(5):575-583.
  17. Katz AJ, Kang J. Stereotactic body radiotherapy as treatment for organ confined low- and intermediate-risk prostate carcinoma, a 7-year study. Front Oncol. 2014; 4:240.
  18. Katz AJ, Santoro M, Diblasio F, Ashley R. Stereotactic body radiotherapy for localized prostate cancer: disease control and quality of life at 6 years. Radiat Oncol. 2013; 8(1):118.
  19. King CR, Brooks JD, Gill H, Presti JC Jr. Long-term outcomes from a prospective trial of stereotactic body radiotherapy for low-risk prostate cancer. Int J Radiation Oncology Biol Phys. 2012; 82(2):877-882.
  20. King CR, Brooks JD, Gill H, et al. Stereotactic body radiotherapy for localized prostate cancer: interim results of a prospective phase II clinical trial. Int J Radiat Oncol Biol Phys. 2009; 73(4):1043-1048.
  21. King CR, Collins S, Fuller D, et al. Health-related quality of life after stereotactic body radiation therapy for localized prostate cancer: results from a multi-institutional consortium of prospective trials. Int J Radiat Oncol Biol Phys. 2013a; 87(5):939-945.
  22. King CR, Freeman D, Kaplan I, et al. Stereotactic body radiotherapy for localized prostate cancer: pooled analysis from a multi-institutional consortium of prospective phase II trials. Radiother Oncol. 2013b; 109(2):217-221.
  23. Kondziolka D, Ong JG, Lee JY, et al. Gamma Knife thalamotomy for essential tremor. J Neurosurg. 2008; 108(1):111-117.
  24. Kondziolka D, Perez B, Flickinger JC, et al. Gamma knife radiosurgery for trigeminal neuralgia: Results and expectations. Arch Neurol. 1998; 55(12):1524-1529.
  25. Koong AC, Christofferson E, Le QT, et al. Phase II study to assess the efficacy of conventionally fractionated radiotherapy followed by a stereotactic radiosurgery boost in patients with locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys. 2005; 63(2):320-323.
  26. Madsen BL, Hsi RA, Pham HT, et al. Stereotactic hypofractionated accurate radiotherapy of the prostate (SHARP), 33.5 Gy in five fractions for localized disease: first clinical trial results. Int J Radiat Oncol Biol Phys. 2007; 67(4):1099-1105.
  27. Mahadevan A, Miksad R, Goldstein M, et al. Induction gemcitabine and stereotactic body radiotherapy for locally advanced nonmetastatic pancreas cancer. Int J Radiat Oncol Biol Phys. 2011; 81(4):e615-622. 
  28. Maniakas A, Saliba I. Microsurgery versus stereotactic radiation for small vestibular schwannomas: a meta-analysis of patients with more than 5 years' follow-up. Otol Neurotol. 2012; 33(9):1611-1620.
  29. Massawa S, Salame C, Flickinger JC, et al. Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg. 2001; 94(1):14-20.
  30. McBride SM, Wong DS, Dombrowski JJ, et al. Hypofractionated stereotactic body radiotherapy in low-risk prostate adenocarcinoma: preliminary results of a multi-institutional phase 1 feasibility trial. Cancer. 2012; 118(15):3681-3690.
  31. Nataf F, Schlienger M, Lefkopoulos D, et al. Radiosurgery of cerebral arteriovenous malformations in children: a series of 57 cases. Int J Radiat Oncol Biol Phys. 2003; 57(1):184-195.
  32. Obayomi-Davies O, Kole TP, Oppong B, et al. Stereotactic accelerated partial breast irradiation for early-stage breast cancer: rationale, feasibility, and early experience using the CyberKnife radiosurgery delivery platform. Front Oncol. 2016; 6:129.
  33. Ohye C, Higuchi Y, Shibazaki T, et al. Gamma knife thalamotomy for Parkinson disease and essential tremor: a prospective multicenter study. Neurosurgery. 2012; 70(3):526-535.
  34. Ohye C, Shibazaki T, Zhang J, Andou Y. Thalamic lesions produced by gamma thalamotomy for movement disorders. J Neurosurg. 2002; 97 (Suppl 5):600-606.
  35. Ponsky LE, Mahadevan A, Gill IS, et al. Renal radiosurgery: initial clinical experience with histological evaluation. Surg Innov. 2007; 14(4):265-269.
  36. Ricardi U, Filippi AR, Guarneri A, et al. Stereotactic body radiation therapy for lung metastases. Lung Cancer. 2012; 75(1):77-81.
  37. Rule W, Timmerman R, Tong L, et al. Phase I dose-escalation study of stereotactic body radiotherapy in patients with hepatic metastases. Ann Surg Oncol. 2011; 18(4):1081-1087.
  38. Sawrie SM, Fiveash JB, Caudell JJ. Stereotactic body radiation therapy for liver metastases and primary hepatocellular carcinoma: normal tissue tolerances and toxicity. Cancer Control. 2010; 17(2):111-119.
  39. Shaw E, Scott CS, Souhami L, et al. Single dose radiosurgical treatment or recurrent previously irradiated primary brain tumors and brain metastases: final report of the RTOG protocol 90-50. Int J Rad Oncol Biol Phys. 2000; 47(2):291-298.
  40. Starke RM, Przybylowski CJ, Sugoto M, et al. Gamma Knife radiosurgery of large skull base meningiomas. J Neurosurg. 2015; 122(2):363-372.
  41. Su PC, Tseng H, Liu H, et al. Subthalamotomy for advanced Parkinson disease. J Neurosurg. 2002; 97(3):598-606.
  42. Svedman C, Sandström P, Pisa P, et al. A prospective Phase II trial of using extracranial stereotactic radiotherapy in primary and metastatic renal cell carcinoma. Oncol. 2006; 45(7):870-875.
  43. Timmerman RD, Park C, Kavanagh BD. The North American experience with stereotactic body radiation therapy in non-small cell lung cancer. J Thorac Oncol. 2007; 2(7 Suppl 3):S101-S112.
  44. Timmerman R, Paulus R, Galvin J, et al. Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA. 2010; 303(11):1070-1076.
  45. Tse RV, Hawkins M, Lockwood G, et al. Phase I study of individualized stereotactic body radiotherapy for hepatocellular carcinoma and intrahepatic cholangiocarcinoma.  J Clin Oncol. 2008; 26(4):657-664. 
  46. Vermeulen S, Haas J. CyberKnife stereotactic body radiotherapy and CyberKnife accelerated partial breast irradiation for the treatment of early breast cancer. Transl Cancer Res 2014; 3(4):295-302.
  47. Wahl DR, Stenmark MH, Tao Y, et al. Outcomes after stereotactic body radiotherapy or radiofrequency ablation for hepatocellular carcinoma. J Clin Oncol. 2016; 34(5):452-459.
  48. Wang XS, Rhines LD, Shiu AS, et al. Stereotactic body radiation therapy for management of spinal metastases in patients without spinal cord compression: a phase 1-2 trial. Lancet Oncol. 2012; 13(4):395-402.
  49. Yu JB, Cramer LD, Herrin J, et al. Stereotactic body radiation therapy versus intensity-modulated radiation therapy for prostate cancer: comparison of toxicity. J Clin Oncol. 2014; 32(12):1195-1201.
  50. Zhang N, Pan L, Zhong J, et al. Gamma knife radiosurgery for jugular foramen schwannomas. J Neurosurg. 2002; 97(5 Suppl):456-458.
  51. Zheng X, Schipper M, Kidwell K, et al. Survival outcome after stereotactic body radiation therapy and surgery for stage I non-small cell lung cancer: A meta-analysis. Int J Radiat Oncol Biol Phys, 2014; 90(3):603-611.
  52. Zimmermann FB, Geinitz H, Schill S, et al. Stereotactic hypofractionated radiotherapy in stage I (T1-2 N0 M0) non-small-cell lung cancer (NSCLC). Acta Oncol. 2006; 45(7):796-801.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Healthcare Research and Quality. Stereotactic body radiation therapy. Technical Brief Number 6. 2011 May. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/92/661/StereotacticBody_TechBrief6_20110502.pdf. Accessed on April 6, 2017.
  2. American College of Radiology (ACR). ACR Appropriateness Criteria® : Available at: http://www.acr.org/Quality-Safety/Appropriateness-Criteria. Accessed on April 6, 2017.
    • Early-Stage Non–Small-Cell Lung Cancer. 2013.
    • Multiple Brain Metastases. 2014.
    • Non-Spine Bone Metastases. 2014.
    • Nonsurgical treatment for non-small-cell lung cancer: good performance status/definitive intent. 2014.
    • Rectal Cancer—Metastatic Disease at Presentation. 2014.
    • Spinal Bone Metastases. 2012.
  3. American College of Radiology (ACR). Practice Guidelines and Technical Standards. Available at: http://www.acr.org/Quality-Safety/Standards-Guidelines. Accessed on April 6, 2017.
    • Practice Guideline for the Performance of Brain Stereotactic Radiosurgery. 2016.
    • Practice Guideline for the Performance of Stereotactic Body Radiation Therapy. 2014.
  4. American Society for Therapeutic Radiation Oncology. Model Policy: Stereotactic Body Radiation Therapy (SBRT). April 17, 2013. For additional information visit the ASTRO website: https://www.astro.org/uploadedFiles/Main_Site/Practice_Management/Reimbursement/2013HPcoding%20guidelines_SBRT_Final.pdf. Accessed on April 6, 2017.
  5. Linskey ME, Andrews DW, Asher AL, et al. The role of stereotactic radiosurgery in the management of patients with newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J NeuroOncol. 2010; 96(1):45-68.
  6. Lutz S, Berk L, Chang E, et al. Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011; 79(4):965-976.
  7. NCCN Clinical Practice Guidelines in Oncology™ (NCCN). © 2017 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on April 6, 2017.
    • Central Nervous System Cancers (V.1.2016). Revised on July 25, 2016.
    • Colon Cancer (V.2.2017). Revised on March 13, 2017.
    • Hepatobiliary Cancers (V.1.2017). Revised on March 15, 2017.
    • Non-Small Cell Lung Cancer (V.5.2017). Revised on March 16, 2017.
    • Pancreatic Adenocarcinoma (V.1.2017). Revised on February 24, 2017.
    • Prostate Cancer (V.2.2017). Revised on February 21, 2017.
    • Rectal Cancer (V.3.201766) Revised on March 13, 2017.
  8. Zesiewicz TA, Elble R, Louis ED, et al. Evidence-based guideline update: Treatment of essential tremor: Report of the Quality Standards Subcommittee of the American Academy of Neurology. 2011; 77(19):1752-1755.
Websites for Additional Information
  1. American Association of Neurological Surgeons (AANS). Stereotactic Radiosurgery. July 2015. Available at: http://www.aans.org/en/Patient%20Information/Conditions%20and%20Treatments/Stereotactic%20Radiosurgery.aspx. Accessed on April 6, 2017.
  2. American College of Radiology/Radiological Society of North America. Radiation Therapy. Available at: http://www.radiologyinfo.org/en/info.cfm?pg=intro_onco. Accessed on April 6, 2017.
  3. International Radiosurgery Support Association. Available at: http://www.irsa.org. Accessed on April 6, 2017.
  4. U.S. National Institutes of Health (NIH). National Cancer Institute (NCI): Dictionary of Cancer Terms. Available at: http://www.cancer.gov/dictionary. Accessed on April 6, 2017.
Index

Acromegaly
Arteriovenous Malformations
Cushing's Disease
Cyberknife
Fractionated Stereotactic Radiotherapy
Gamma Beam
Gamma Knife
Stereotactic Body Radiation Therapy
Stereotactic Body Radiosurgery
SBRT
Stereotactic Radiosurgery
SRS
X-Knife®

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History
Status Date Action
Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review.
Reviewed 05/03/2017 Hematology/Oncology Subcommittee review. Updated Rationale, Coding and References sections.
Revised 11/03/2016 MPTAC review.
Revised 11/02/2016 Hematology/Oncology Subcommittee review. Updated Reference section. Clarification to MN statement regarding Gleason score. Updated Rationale, Coding and Reference sections.
Reviewed 11/05/2015 MPTAC review.
Reviewed 11/04/2015 Hematology/Oncology Subcommittee review. Updated Rationale and References. Changed document number from SURG.00017 to THER-RAD-00010. Removed ICD-9 codes from the Coding section.
Revised 11/13/2014 MPTAC review.
Revised 11/12/2014 Hematology/Oncology Subcommittee review. Clarification to Medically Necessary Position Statement for prostate cancer. Updated References. Updated Coding section and removed HCPCS codes G0173, G0251 deleted 12/31/2014.
Revised 07/08/2014 MPTAC review.
Revised 06/20/2014 Hematology/Oncology Subcommittee review. Added prostate cancer to Medically Necessary Position Statement and edited Investigational and Not Medically Necessary Position Statement. Updated Rationale and References.
Reviewed 05/15/2014 MPTAC review.
Reviewed 05/14/2014 Hematology/Oncology Subcommittee review. Updated References.
Revised 11/14/2013 MPTAC review.
Revised 11/13/2013 Hematology/Oncology Subcommittee review. Updated Position Statement; removed criteria that "extracranial disease is stable" when treating cranial lesions and removed location specific criteria (jugular foramen or vestibular) for schwannomas. Updated Rationale, Coding and References sections.
Revised 08/08/2013 MPTAC review.
Revised 07/11/2013 Hematology/Oncology Subcommittee review. Added liver metastases, spinal metastases, reirradiation to Medically Necessary Position Statements. Updated Rationale, Definitions, Coding and References.
Revised 11/08/2012 MPTAC review.
Revised 11/07/2012 Hematology/Oncology Subcommittee review. Clarification to Investigational and Not Medically Necessary statement for primary or metastatic cancers of the kidney, prostate, liver, colon and pancreas. Added metastatic lung cancer to SBRT Position Statement. Updated Rationale and References. Updated Coding section to include 01/01/2013 CPT changes.
Revised 05/10/2012 MPTAC review.
Revised 05/09/2012 Hematology/Oncology Subcommittee review. Medically Necessary criteria clarified for brain metastases and revised to include ECOG status. Rationale, References and Web Sites updated.
Revised 05/19/2011 MPTAC review.
Revised 05/18/2011 Hematology/Oncology Subcommittee review. Medically Necessary criteria for brain metastases revised. Investigational and Not Medically Necessary statement when criteria not med added. Rationale, References and coding updated.
Reviewed 11/18/2010 MPTAC review.
Reviewed 11/17/2010 Hematology/Oncology Subcommittee review. American Association of Neurological Surgeons (AANS), the Congress of Neurological Surgeons (CNS), and Joint Tumor Section (AANS/CNS) 2010 guideline added to Rationale.
Revised 05/13/2010 MPTAC review.
Revised 05/12/2010 Hematology/Oncology Subcommittee review. SRS medically necessary criteria for solitary or multiple brain metastases clarified. Lesion size for SBRT of the lung changed to 5cm. References updated.
Revised 05/21/2009 MPTAC review.
Revised 05/20/2009 Hematology/Oncology Subcommittee review. Medically necessary criteria clarified. Rationale, coding and references updated.
Revised 11/20/2008 MPTAC review.
Revised 11/19/2008 Hematology/Oncology Subcommittee review. Non-small cell lung cancer (NSCLC) added to medically necessary indications. Colorectal and kidney cancer added to the investigational and not medically necessary criteria. Clarification of medically necessary and the investigational and not medically necessary criteria for primary and metastatic cancers. Rationale and references updated. Updated Coding section to include 01/01/2009 CPT changes; removed CPT 61793 deleted 12/31/2008.
Reviewed 05/15/2008 MPTAC review. 
Reviewed 05/14/2008 Hematology/Oncology Subcommittee review. Rationale, background and references updated. 
  01/01/2008 Updated Coding section with 01/01/2008 CPT changes.  The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary."  This change was approved at the November 29, 2007 MPTAC meeting.
Revised 05/17/2007 MPTAC review. Revised investigational/not medically necessary criteria to include lung, pancreatic, liver and prostate cancer. Updated rationale and references. 
  01/01/2007 Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed HCPCS G0243 deleted 12/31/2006, and G0242, G0338 deleted 12/31/2005.
Revised 06/08/2006 MPTAC review. Revised medically necessary criteria to include spinal lesions. Updated references.
Reviewed 03/23/2006 MPTAC review.  References updated.
  01/01/2006 Updated Coding section with 01/01/2006 CPT/HCPCS changes
Revised 04/28/2005 MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations Last Review Date Document # Title
Anthem, Inc. 01/28/2004 SURG.00017 Stereotactic Radiosurgery
WellPoint Health Networks, Inc. 12/02/2004 4.11.08 Stereotactic Radiosurgery and Fractionated Stereotactic Radiosurgery