Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Medical Policy: 06.01.15 
Original Effective Date: October 2003 
Reviewed: August 2011 
Revised: September 2008 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Stereotactic radiosurgery (SRS) is a method of delivering precise high doses of radiation to destroy targeted areas of abnormal tissue such as vascular malformations and malignant or benign tumors, while minimizing the amount of radiation delivered to surrounding normal tissue. Frameless SRS systems monitor and compensate for movement, allowing patients to lie comfortable on the procedure table without anesthesia. Preparation for the procedure involves the use of computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and/or angiography to orient the patient's anatomy to the SRS system.

The most common applications of SRS include treatment of intracranial tumors and malignancies, including primary and metastatic tumors, acoustic neuromas, and other benign intracranial tumors such as meningiomas or pituitary adenomas. SRS is an established treatment for arteriovenous malformations. Trigeminal neuralgia that has been resistant to other therapies has responded to SRS.  Intracranial metastases have been considered especially amenable to SRS due to their small spherical size and non-infiltrative borders. Brain metastases are a frequent occurrence, seen in 25% to 30% of all patients with cancer, particularly in those with lung, breast, or colon cancer, or melanoma. Primary brain tumors, such as gliomas, are more challenging to treat due to their generally larger size and infiltrative borders.

Stereotactic body radiotherapy refers to use at any extracranial site. As with stereotactic intracranial irradiation, multiple static fields or converging arc beams target the extracranial tumor from many different directions. Stereotactic body radiation therapy is rapidly evolving technology with dozens of clinical trials underway.

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Prior Approval: 

Not applicable

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Policy: 

Stereotactic radiosurgery may be considered medically necessary for treatment of any of the following indications:

• intracranial arteriovenous malformations
• acoustic neuromas
• pituitary adenomas
• non-resectable, residual, or recurrent meningiomas
• solitary or multiple brain metastases 
• primary malignancies of the CNS, including but not limited to high-grade gliomas (initial treatment or treatment of recurrence)
• trigeminal neuralgia refractory to medical management
• other intracranial and spinal cord lesions
• nasopharyngeal tumors

Stereotactic body radiation therapy may be considered medically necessary for treatment of any of the following indications:

• primary lung cancer and  lung metastases
• liver metastasis
• pancreatic tumors
• primary or metastatic spinal or vertebral body tumors
• previous radiation therapy to an area for which conventional radiation therapy is no longer an option, i.e. maximum dose to critical structures has been reached

Stereotactic radiosurgery is considered investigational for treatment of all indications not listed above, including but not limited to, the following:

• chronic pain
• epilepsy
• Parkinson disease

Stereotactic body radiation therapy is considered investigational for all extracranial indications not listed above including, but not limited to:

• Primary and metastatic tumors of the prostate
• Primary and metastatic tumors of the retroperitoneum and pelvis

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• 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)
• 61781 Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)
• 61782 Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure)
• 61783 Stereotactic computer-assisted (navigational) procedure; spinal (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)
• 77280 Therapeutic radiology simulation-aided field setting; simple
• 77285 Therapeutic radiology simulation-aided field setting; intermediate
• 77290 Therapeutic radiology simulation-aided field setting; complex
• 77295 Therapeutic radiology simulation-aided field setting; 3-dimensional
• 77300 Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician
• 77315 Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations)
• 77331 Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician
• 77332 Treatment devices, design and construction; simple (simple block, simple bolus) 
• 77333 Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)
• 77334 Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)
• 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
• 77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services           
• 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
• G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session
• G0251 Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum 5 sessions per course of treatment
• 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          

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Selected References: 

• Tome WA, Mehta MP, Meeks SL, Buatti JM  Fractionated stereotactic radiotherapy: a short review. Technol Cancer Res Treat. 2002 Jun;1(3):153-72.
• Ryu S, et al. Image-guided and intensity-modulated radiosurgery for patients with spinal metastasis.  Cancer. 2003 Apr 15;97(8):2013-8.
• Hof H, et al.  Stereotactic single-dose radiotherapy of stage I non-small-cell lung cancer (NSCLC). Int J Radiat Oncol Biol Phys. 2003 Jun 1;56(2):335-41.
• Qiao X, Tullgren O, Lax I et al. The role os radiotherapy in treatment of stage I non-small cell lung cancer.  Lung Cancer 2003; 41(1):1-11.
• Hof H, Herfarth KK, Munter M et al. Stereotactic single-dose radiotherapy of stage I non-small cell lung cancer (NSCLC). Int J Radiat Oncol Biol Phys. 2003; 56(2):335-41.
• Alberta Heritage Foundation for Medical Research (AHRMR). Body stereotactic radiosurgery. Edmonton, Canada: AHFMR; 1998.
• Alberta Heritage Foundation for medical Research (AHRMR). Cyberknife. Edmonton, Canada: AHRMR; 1999.
• Whyte RI, Crownover R, Murphy MJ et al. Stereotactic radiosurgery for lung tumors: preliminary report of a phase 1 trial.   Ann Thorac Surg. 2003; 75(4):1097-101.
• Gunven P, Blomgen H, Lax I. radiosurgery for recurring liver metastases after hepatectomy, Hepatogastroenterology. 2003; 50(52):1201-4.
• Herfarth KK, Debus J, Lohr F. Stereotactic single-dose radiation therapy of liver tumors: results of a phase I/II trial. J Clin Oncol. 2001; 19910:164-70.
• Timmerman R, Papiez L, Suntharalingam M. Extracranial stereotactic radiation delivery: expansion of technology beyond the brain. Technol Cancer Res Treat. 2003; 2(2):153-60.
• Koong AC, Le QT, Ho A et al. A Phase I study of stereotactic radiosurgery in patients with locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys. 2004; 58(4):1017-21.
• Murphy MJ, Change SD, Gibbs IC et al. Patterns of patient movement during frameless image-guided radiosurgery. Int J Radiat Oncol biol Phys. 2003; 55(5):1400-8.
• ECRI. Stereotactic radiosurgery for extracranial tumors. ECRI Hotline; 2004.
• Henzel M, gross MW, Hamm K et al. Significant tumor volume reduction of meningiomas after stereotactic radiotherapy: results of a prospective multicenter study. Neurosurgery. 2006 Dec;59(6):1188-94; discussion 1194.
• Collins SP, Coppa ND, Zhang Y et al. CyberKnife radiosurgery in the treatment of complex skull base tumors: analysis of treatment planning parameters. Radiat Oncol. 2006 Dec 16; 1:46.
• Adler JR Jr, Gibbs IC, Puataweepong P et al. Visual field preservation after multisession CyberKnife radiosurgery for peroptic lesions. Neurosurgery. 2006 Aug;59(2):244-54.
• Okunieff P, Petersen Al, Philip A et al. Stereotactic Body Radiation Therapy (SBRT) for lung metastases. Acta Oncol. 2006;45(7):808-817.
• Pennathur A, Luketich JD, Burton S et al. Stereotactic radiosurgery for the treatment of lung neoplasm: initial experience. Ann Thorac Surg. 2007;83(5):1820-24.
• Hara R, Itami J, Kondo T et al. Clinical outcomes of single-fraction stereotactic radiation therapy of lung tumors. Cancer. 2006;106(6):1347-52.
• Suh JH. Stereotactic radiosurgery for the management of brain metastases. N Engl J Med. 2010 Mar 25;362(12):1119-27.
• Rwigema JC, Parikh SD, Heron DE et al. Stereotactic body radiotherapy in the treatment of advanced adenocarcinoma of the pancreas. Am J Clin Oncol. 2010 Mar 19 [Epub ahead of print].
• Timmerman R, Paulus R, Galvin J et al. Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA. 2010 Mar 17; 303(11): 1070-6.
• Kim JH, Kim MS, Yoo SY et al. Stereotactic body radiotherapy for refractory cervical lymph node recurrence of nonanaplastic thyroid cancer. Otolaryngol Head Neck Surg. 2010 Mar; 142(3):338-43.
• Grills IS, Mangona VS, Welsh R et al. Outcomes after stereotactic lung radiotherapy or wedge resection for stage I non-small-cell lung cancer. J Clin Oncol. 2010 Feb 20; 28(6): 928-35. Epub 2010 Jan 11.
• Katz AJ, Santoro M, Ashley R et al. Stereotactic body radiotherapy for organ-confined prostate cancer. BMC Urol. 2010 Feb 1; 10:1
• Rajagopalan MS, Heron DE. Role of PET/CT imaging in stereotactic body radiotherapy. Future Oncol. 2010 Feb; 6(2):305-17.
• Tipton KN, Sullivan N, Bruening W et al. Steroetactic Body Radiation Therapy. Technical Brief No. 6. (Prepared by ECRI Institute Evidence-based Practice Center inder Contract No. HHSA-290-02-0019.) AHRQ Publication No. 10 (11)-AHC058-EF. Rockville, MD: Agency for Healthcare Research and Quality. May 2011. Available at www.effecti vehealthcare.ahrq.gov/reports/final.cfm.
• King CR, Brooks JD, Gill H et al. Long-term outcomes from a prospective trial of stereotactic body radiotherapy for low-risk prostate cancer. Int J Radiat Oncol Biol Phys. 2011 Feb 5. [Epub ahead of print].
• The BS, Ishiyama H, Mathews T et al. Stereotactic body radiation therapy (SBRT) for genitourinary malignancies. Discov Med. 2010 Sep; 10(52):255-62.
• Chi A, Liao Z, Nguyen NP et al. Systemic review of the patterns of failure following stereotactic body radiation therapy in early-stage non-small-cell lung cancer: clinical implications. Radiother Oncolo. 2010; 94(1): 1-11.
• Baba F, Shibamoto Y, Ogino H et al. Clinical outcomes of stereotactic body radiotherapy for stage I non-small-cell lung cancer using different doses depending on tumor size. Radiat Oncol. 2010; 5:81.
• Grills IS, Mangona VS, Welsh R et al. Outcomes after stereotactic lung radiotherapy or wedge resection for stage I non-small-cell lung cancer. J Clin Oncol. 2010; 28(6):928-35.
• Kagara N, Nakano Y, Watanabe A et al. Curative-intent stereotactic body radiation therapy for residual breast cancer liver metastasis after systemic chemotherapy. Breast Cancer. 2011 Jul 5. [Epub ahead of print]
• Barney BM, Olivier KR, Macdonald OK et al. Clinical outcomes and dosimetric considerations using stereotactic body radiotherapy for abdominopelvic tumors. Am J Clin Oncol. 2011 Jun 8. [Epub ahead of print]
• Andolino DL, Johnson CS, Maluccio M et al. Stereotactic body radiotherapy for primary hepatocellular carcinoma. Int J Radiat Oncol Biol Phys. 2011 Jun 7. [Epub ahead of print]
• Dietrich S, Gibbs IC. The CyberKnife in clinical use: current roles, future expectations. Front Radiat Ther Oncol. 2011; 43:181-94. Epub 2011 May 20.
• ECRI Institute. Stereotactic Body Radiation Therapy for Prostate Cancer. Plymouth Meeting (PA): ECRI Institute; 2011 May 9. 8 p. [ECRI hotline response]. Also available: http://www.ecri.org
• ECRI Institute.  Stereotactic Radiosurgery for Primary Lung Cancer and Lung Metastases. Plymouth Meeting (PA): ECRI Institute; 2011 Mar 3. 15 p. [ECRI hotline response]. Also available: http://www.ecri.org 

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Policy History: 

Date                                       Reason                               Action

August 2011                          Annual review                     Policy renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.