Skip to main content
HealthPartners

Coverage criteria policies

Stereotactic radiosurgery and stereotactic body radiation therapy

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for stereotactic radiosurgery and stereotactic body radiation therapy.

Coverage

Stereotactic radiosurgery and stereotactic body radiation therapy are generally covered subject to the indications listed below, and per your plan documents.

Craniospinal stereotactic radiosurgery (SRS)

Indications that are covered

Conditions involving the brain and spinal cord, ≤ 4 cm in greatest diameter, including but not limited to:

  1. Primary gliomas of the brain when used following failure of external beam radiation therapy, or in conjunction with external beam radiation as a planned field reductions or “boost”.
  2. Recurrent, symptomatic metastatic brain lesions, preferably three, and no more than four, after failure of external beam radiation therapy; ideally extracranial metastatic sites are controlled.
  3. Recurrent spinal or paraspinal tumors that are symptomatic after external beam radiation therapy and or resection have failed or, are not clinically possible or feasible.
  4. Arteriovenous malformations
  5. Aneurysms
  6. Acoustic neuroma/ vestibular schwannoma/acoustic neurinoma/acoustic neurilemoma
  7. Meningiomas
  8. Hemangiomas
  9. Pituitary tumors
  10. Craniopharnygiomas
  11. Tumors of the pineal gland
  12. Trigeminal neuralgia refractory to prior, aggressive medical intervention
  13. Skull base tumors

Indications that may be covered under a prior authorized, case by case, setting include but are not limited to:

  1. Nasopharyngeal tumors when external beam radiation therapy has failed, or in conjunction with external beam as a planned field reduction or “boost”.
  2. Uveal melanoma
  3. Parkinsonism refractory to medical management and/or patient has comorbidities for increased surgical or anesthetic risk.

Indications not covered:

  1. Epilepsy unrelated to a structural lesion noted above.
  2. Cluster headaches
  3. Behavioral health disorders (e.g.Obsessive compulsive disorder)

Stereotactic body radiation therapy (SBRT)

Indications that are covered:

  1. Patients with biopsy proven, non-small cell cancer of the lung, with a negative metastatic work up
  2. Prostate cancer-Low risk disease as definitive treatment for patients who meet the following:
    1. Gleason score ≤6,
    2. Tumors stage T1-T2a,
    3. Serum PSA level below 10ng/mL.
  3. Treatment of malignancies located near vital organs or structures which require precise delivery of high dose radiation.

Indications not covered:

Stereotactic body radiation therapy is not covered for any other indications including but not limited to:

  1. Breast cancer
  2. Pancreatic cancer

Definitions

Fractionated stereotactic radiotherapy (FSRT) - FSRT is the use of a noninvasive relocatable head frame to deliver radiation therapy with stereotactic technique. This is used for lesions in highly sensitive parts of the brain, and may be administered daily for several weeks.

Stereotactic radiosurgery (SRS) - SRS is the irradiation of intracranial and other applicable targets localized by an imaging compatible stereotactic device. Radiosurgery is used to treat small lesions in relatively inaccessible regions of the brain where safe surgical resection is not possible. Radiosurgery delivers a single fraction large dose of radiation as opposed to multiple treatments of lower dose, as in conventional radiotherapy. Examples of brand names of machines that perform this surgery are CyberKnife®, X-Knife®, Clinac®, Gamma Knife and others.

Stereotactic body radiation therapy (SBRT) -SBRT is “an external beam radiation therapy method used to very precisely deliver a high dose of radiation to an extracranial target within the body, using either a single dose or a smaller number of fractions.” SBRT is the treatment of an extracranial lesion with a single or very few (≤5) high-dose fractions.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

32701

Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment

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 (List separately in addition to code for primary procedure)

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 (List separately in addition to code for primary procedure)

61800

Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)

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 (List separately in addition to code for primary procedure)

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

77373

Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

77432

Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)

77435

Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

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 5 sessions per course of treatment

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

References:

  1. ASTRO, (2014a) Model Policies, Stereotactic Body Radiation Therapy (SBRT).
  2. ASTRO, (2014b) Model Policies, Stereotactic radiosurgery (SRS). 2014.
  3. Balaban, E. P., Mangu, P. B., Khorana, A. A., Shah, M. A., Mukherjee, S., Crane, C. H., ... & Engebretson, A. (2016). Locally advanced, unresectable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology34(22), 2654-2668.
  4. Chen, CC. Stereotactic cranial radiosurgery. In: UpToDate, Wen, PY (Ed), UpToDate, Waltham, MA. (Accessed on November 14, 2017.)
  5. de Geus, S. W., Eskander, M. F., Kasumova, G. G., Ng, S. C., Kent, T. S., Mancias, J. D., ... & Tseng, J. F. (2017). Stereotactic body radiotherapy for unresected pancreatic cancer: A nationwide review. Cancer123(21), 4158-4167.
  6. ECRI Institute, Hotline Response, “Stereotactic Body Radiation Therapy for Treating Prostate Cancer.” April 2015.
  7. Hayes, Inc. Hayes Health Technology Brief. Stereotactic Body Radiation Therapy with CyberKnife Robotic Radiosurgery System (Accuray Inc.) for Monotherapy of Primary Localized Prostate Cancer. Lansdale, PA: Hayes, Inc.; October, 2016. Reviewed October, 2017.
  8. Hayes, Inc. Hayes Medical Technology Directory Report. CyberKnife Robotic Radiosurgery System (Accuray Inc.) for Treatment of Prostate Cancer. Lansdale, PA: Hayes, Inc.; July, 2014. Reviewed May, 2016.
  9. Hayes, Inc. Hayes Medical Technology Directory Report. Robotically assisted stereotactic radiosurgery for intracranial indications. Lansdale, PA: Hayes, Inc.; July, 2011. Archived August, 2016.
  10. Hayes, Inc. Hayes Health Technology Brief. Stereotactic Body Radiation Therapy with CyberKnife Robotic Radiosurgery System (Accuray Inc.) Boost Treatment in Primary Localized Prostate Cancer. Lansdale, PA: Hayes, Inc.; October, 2016. Reviewed October, 2017.
  11. Hayes, Inc. Hayes Medical Technology Directory Report. Stereotactic Radiosurgery for Arteriovenous Malformations and Intracranial Tumors. Lansdale, PA: Hayes, Inc.; January, 2009. Archived February, 2014.
  12. Hayes, Inc. Hayes Directory, Stereotactic Radiosurgery for Trigeminal Neuralgia and Movement Disorders. Lonsdale, PA: Hayes, Inc. February 2015. Reviewed February 2017.
  13. Heinzerling, JH. Stereotactic body radiation therapy for primary and metastatic lung tumors. In: UpToDate, Friedberg, JS (Ed), UpToDate, Waltham, MA. (Accessed on November 14, 2017.)
  14. Hickey, BE, Lehman, M, Francis, DP, See, AM. Partial breast irradiation for early breast cancer Cochrane Database of Systematic Reviews Issue 7. Art. No.: CD007077.DOI: 10.1002/14651858.CD007077.pub3.
  15. International RadioSurgery Association (IRSA). Stereotactic radiosurgery for patients with intracranial arteriovenous malformations (AVM). Harrisburg (PA): International RadioSurgery Association (IRSA); 2009. (Radiosurgery practice guideline report; no. 2-03).
  16. International RadioSurgery Association (IRSA). Stereotactic radiosurgery for patients with pituitary adenomas. Harrisburg (PA): International RadioSurgery Association (IRSA); 2004. (Radiosurgery practice guideline report; no. 3-04).
  17. International RadioSurgery Association (IRSA). Stereotactic radiosurgery for patients with vestibular schwannomas. Harrisburg (PA): International RadioSurgery Association (IRSA); 2006. (Radiosurgery practice guideline report; no. 4-06).
  18. Kang, D. W., Lee, S. C., Park, Y. G., & Chang, J. H. (2012). Long-term results of Gamma Knife surgery for uveal melanomas. Journal of neurosurgery117(Special Suppl), 108-114.
  19. Katz, A. J., & Kang, J. (2014). Stereotactic body Radiotherapy as treatment for organ confined low- and intermediate-risk prostate carcinoma, a 7-Year study. Frontiers in Oncology doi:10.3389/fonc.2014.00240
  20. King, C. R., Freeman, D., Kaplan, I., Fuller, D., Bolzicco, G., Collins, S., … Katz, A. (2013). Stereotactic body radiotherapy for localized prostate cancer: Pooled analysis from a multi-institutional consortium of prospective phase II trials. Radiotherapy and Oncology,109 (2), 217–221. doi:10.1016/j.radonc.2013.08.030
  21. Linskey, M. E., Andrews, D. W., Asher, A. L., Burri, S. H., Kondziolka, D., Robinson, P. D., ... & McDermott, M. (2010). The role of stereotactic radiosurgery in the management of patients with newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. Journal of neuro-oncology96(1), 45-68.
  22. Loeffler, JS. Overview of the treatment of brain metastases. In: UpToDate, DeAngelis, LM (Ed), UpToDate, Waltham, MA. (Accessed on November, 2017.)
  23. Loeffler, JS & Shih, HA. Radiation therapy of pituitary adenomas. In: UpToDate, Snyder, PJ (Ed), UpToDate, Waltham, MA. (Accessed on October, 2016.)
  24. Park, JK, Vernick, DM & Ramakrishna, N. Vestibular schwannoma (acoustic neuroma). In: UpToDate, Loeffler, JS & Wen, PY (Eds), UpToDate, Waltham, MA. (Accessed on October, 2016.)
  25. Patil CG, Pricola K, Sarmiento JM, Garg SK, Bryant A, Black KL. Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases. Cochrane Database of Systematic Reviews 2017, Issue 9. Art. No.: CD006121.
  26. Régis, J., Tuleasca, C., Resseguier, N., Carron, R., Donnet, A., Gaudart, J., & Levivier, M. (2016). Long-term safety and efficacy of gamma knife surgery in classical trigeminal neuralgia: A 497-patient historical cohort study. Journal of Neurosurgery, 124(4), 1079–1087. doi:10.3171/2015.2.jns142144
  27. Ryan, DP, Mamom, H. Initial chemotherapy and radiation for nonmetastatic, locally advanced, unresectable and borderline resectable, exocrine pancreatic cancer. In: UpToDate, Goldberg, RM, Ashley, SW and Willett, CG (Eds), UpToDate, Waltham, MA. (Accessed on January 3, 2018)
  28. Sanda, M. G., Chen, R. C., Crispino, T., Freedland, S., Nelson, M. D., Reston, J., ... & Cadeddu, J. A. (2017). Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Risk6, 27.
  29. Sarici, A. M., & Pazarli, H. (2013). Gamma-knife-based stereotactic radiosurgery for medium-and large-sized posterior uveal melanoma. Graefe's Archive for Clinical and Experimental Ophthalmology251(1), 285-294.
  30. West, JH, VAllieres, E, Schild, SE. Management of state I and stage II non-small cell lung cancer. In: UpToDate, Jett, JR, Friedberg, JS, Lilenbaum, RC (Eds), UpToDate, Waltham, MA. (Accessed on October 3, 2016.)
  31. Yu, J. B., Cramer, L. D., Herrin, J., Soulos, P. R., Potosky, A. L., & Gross, C. P. (2014). Stereotactic body radiation therapy versus intensity-modulated radiation therapy for prostate cancer: Comparison of toxicity. Journal of Clinical Oncology, 32(12), 1195–1201. doi:10.1200/jco.2013.53.8652

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Go to

Policy activity

  • 07/01/1996 - Date of origin
  • 01/08/2018 - Effective date
Review date
  • 10/2017
Revision date
  • 10/20/2016

Related content