Stereotactic Radiosurgery
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Clinical policy governing when stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) are considered medically necessary for Aetna members; affects providers requesting coverage for these procedures and associated codes.
No material clinical or coverage changes in this revision.
Coverage Criteria for SRS / SBRT
Medical Necessity (eviCore-guided)
Covered when medical necessity criteria are met according to eviCore Healthcare Radiation Therapy Clinical Guidelines
Providers must use eviCore criteria for individual case determination.
Site-specific evidence summaries and implied clinical positioning
Site-specific evidence summaries and implications for clinical use
Kopek et al reported 45 Gy in 3 fractions with severe duodenal/pyloric ulceration in 6/27 patients.
Boike et al: cohorts of 15 patients per dose level; median follow-up up to 30 months.
Yamada et al: median single-fraction dose ~2400 cGy; median follow-up 24 months.
Van De Voorde et al and others report favorable outcomes; NCCN 2015 did not mention SRS as standard for hepatobiliary cancers.
Herman et al: 33 Gy in 5 fractions, median OS 13.9 months, 1-year local control 78%; Buwenge et al pooled analgesic reduction ~71.5%.
Howington et al and Zheng et al summarize guidelines and meta-analysis comparing SBRT and surgery.
Indications with observational / systematic evidence
Contexts with reported favorable outcomes in the cited literature (observational, systematic reviews, meta-analyses):
Evidence heterogeneous; NCCN did not list SRS as a therapeutic option (Version 2.2015).
Meta-analyses and reviews report lower seizure freedom compared with resection but possible neuropsychological advantages.
Concurrent defined as ICI within 2 weeks of SRS-SRT in one study; median OS reported 24.7 months for concurrent group.
Singh et al systematic review and meta-analysis of repeat SRS.
Kobiela et al systematic review.
Indication-level evidence summaries
Findings summarizing clinical evidence by indication (no explicit 'covered when' rules in this excerpt):
Hintenlang et al: single-case dural metastasis treated with 20 Gy in 1 fraction showing near-complete resolution at 6 months.
Kobiela et al systematic review.
Poorthuis et al systematic review.
Zhang and Zhang systematic review and meta-analysis.
Mathieu et al systematic review: tumor control rates high (eg, acromegaly 97%), endocrine remission lower (eg, acromegaly 44%).
Safavi et al systematic review/meta-analysis.
Dumot et al and related analyses report tumor control ~94.1% and facial nerve risk with margin dose ≥13 Gy.
Aggregate initial meaningful pain reduction ~55%, persistent effect ~38%.
Franceschini et al (breast SBRT) and Ma et al (RCC retrospective SABR).
Cranial Stereotactic Radiosurgery — Medically Necessary
Covered when ANY of the following are met:
Cranial SRS with Cyberknife, Gamma Knife, or LINAC; treatment to additional brain lesions beyond 4 may need justification.
Stereotactic Body Radiation Therapy — Medically Necessary
SBRT is considered medically necessary for localized malignant conditions where high-precision high-dose radiotherapy is required, including:
All other clinical sites or indications are considered experimental and investigational but may be considered case-by-case.
Fractionated Stereotactic Radiotherapy — Medically Necessary
Fractionated stereotactic radiotherapy
Fractionation employed when single-fraction SRS is not tolerable due to adjacent critical structures.
Proton Beam Radiosurgery — Cross-reference
Stereotactic proton beam radiosurgery
Cross-reference to CPB 0270.
Experimental and Investigational Indications — Not Medically Necessary
Considered experimental and investigational for indications where effectiveness not established, including (not all-inclusive):
Effectiveness for these indications has not been established; treatments considered experimental/investigational.
The policy lists specific ICD-10 codes not covered for the indications addressed in this Clinical Policy Bulletin. These include codes for epilepsy and recurrent seizures (G40.001–G40.919), cluster headache and trigeminal autonomic cephalgias (G44.001–G44.099), post-traumatic seizures (R56.1), unspecified convulsions (R56.9), and mammographic microcalcification (R92.0). Providers should not expect coverage for SRS/SBRT when those diagnoses are the stated indication under this CPB.
The document cites guideline commentary noting that in certain disease sites NCCN and specialty panels did not endorse SBRT/SRS as a substitute for established therapies. For example, the American College of Radiology/ACR Appropriateness Panel on early-stage cervical cancer stated that although SBRT has preliminary data in other sites, SBRT should not be considered a substitute for brachytherapy because of target motion and the proven outcomes of brachytherapy.
The policy notes that the NCCN Hepatobiliary and Pancreatic guidelines (Version 2.2015) did not list stereotactic radiosurgery as a therapeutic option. Specifically, the Hepatobiliary guideline did not mention SRS, and the Pancreatic adenocarcinoma guideline likewise did not mention SRS as a therapeutic option in the cited guideline version, implying lack of guideline endorsement at that time.
An UpToDate review on vascular malformations states that clinicians should not use stereotactic radiosurgery as the primary treatment for cerebral cavernous malformations. SRS may be considered for surgically inaccessible lesions, but high complication rates in published series and sparse long-term safety data have discouraged routine primary use.
Any clinical site or indication not explicitly listed in the policy’s medically necessary sections is treated as experimental and investigational. The CPB gives examples (e.g., cluster headaches, epilepsy except when associated with AV malformations or brain tumors, and mammographic microcalcifications) and states that all other non-listed indications will be considered on a case-by-case basis and lack established effectiveness.
This Clinical Policy Bulletin is a summary developed to assist in administering plan benefits and does not constitute a contract or a complete listing of plan-specific exclusions. Providers remain responsible for confirming individual plan coverage and any specific exclusions not detailed in this CPB.
The policy identifies the use of SRS/SBRT for certain listed ICD-10 indications (for example, epilepsy/seizures, cluster headaches/TACs, and mammographic microcalcifications) as not supported for coverage under this CPB. These diagnoses are explicitly included among the ICD-10 codes described as not covered for the indications listed.
For operable patients where surgery is the established standard of care (for example, operable stage I–II non–small cell lung cancer), the policy states that surgical resection (lobectomy with mediastinal lymph node sampling) remains the preferred standard; SBRT is positioned primarily for medically inoperable patients or those refusing surgery rather than as a first-line replacement.
Within the provided excerpts there are no explicit ‘not medically necessary’ statements for every indication; however, referenced guidance (e.g., UpToDate on cavernous malformations) advises against using primary SRS for cerebral cavernous malformations in general, reflecting cautious clinical positioning rather than a blanket policy exclusion.
The CPB identifies stereotactic radiosurgery as not supported for indications including cluster headaches, epilepsy (except when treating associated AV malformations or brain tumors), and mammographic microcalcifications. These examples are included in the list of indications considered experimental and investigational.
In the portions of the document provided there are no additional explicit ‘not medically necessary’ criteria beyond the listed ICD-10 exclusions and investigational indications. The CPB and accompanying Aetna notes emphasize that the bulletin is a partial summary and specific not-medically-necessary determinations may depend on plan-specific rules and the eviCore guideline-based medical necessity process.
Coding and Billing
| 20660 | Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure). |
| 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 | Each additional cranial lesion, simple (List separately in addition to code for primary procedure). |
| 61798 | 1 complex cranial lesion. |
| 61799 | 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 | 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. |
| C9795 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, 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. |
| C00-C96 | Malignant neoplasms. |
| D18.00-D18.09 | Hemangioma [hemangioblastoma]. |
| D33.0-D33.2 | Benign neoplasm of brain. |
| G20 | Parkinson's disease. |
| G21.0-G21.9 | Secondary parkinsonism. |
| G25.0 | Essential tremor. |
| G50.0 | Trigeminal neuralgia. |
| I67.1 | Cerebral aneurysm, nonruptured. |
| Q28.2-Q28.3 | Other congenital malformations of circulatory system. |
| G40.001-G40.919 | Epilepsy and recurrent seizures (ICD-10 codes listed as not covered for indications in the CPB). |
| G44.001-G44.099 | Cluster headache and trigeminal autonomic cephalgias (TAC) (listed as not covered). |
| R56.1 | Post traumatic seizures (listed as not covered). |
| R56.9 | Unspecified convulsions (listed as not covered). |
| R92.0 | Mammographic microcalcification found on diagnostic imaging of breast (listed as not covered). |
| exact code | exact description from document |
| No codes listed |
Provider Actions, Prior Authorization, and Documentation
eviCore guideline-based prior authorization
Prior authorization/medical necessity determinations must adhere to eviCore Radiation Therapy Clinical Guidelines. Coverage is contingent on meeting eviCore medical necessity criteria; failure to meet these criteria may result in non-coverage. eviCore guidelines are reviewed annually and may change; draft guidelines are posted 90 days prior to implementation.
- Refer to eviCore Radiation Therapy Clinical Guidelines for medical necessity determinations.
- Coverage contingent on meeting eviCore criteria; non-coverage possible if criteria not met.
Site-specific selection confirmation recommended
Site-specific selection and eligibility features described in trials and reviews should be confirmed when proposing SRS/SBRT for a given anatomic site. Consider trial-defined limits (lesion counts, size limits, resectability) and specialty guideline recommendations when selecting patients.
- Confirm site-specific eligibility criteria from relevant trials and guidelines (lesion count, size, resectability, performance status).
- For additional lesions beyond typical limits (eg, >4 brain metastases) provide further clinical justification.
PA recommended for SRS with concurrent ICI and repeat SRS
Prior authorization is recommended when SRS/SRT is planned concurrently with immune checkpoint inhibitors (ICI) or when repeat SRS is requested for locally recurrent brain metastases. These scenarios have evolving evidence and may require case review and documentation of rationale and timing relative to ICI.
- PA recommended for SRS/SRT concurrent with ICI (concurrent defined in studies as within ~2 weeks).
- PA recommended for repeat SRS for locally recurrent brain metastases; include prior treatment history and interval since prior RT.
Prior authorization: study-based inclusion criteria
Prior authorization requests that reflect study-based inclusion criteria should document lesion counts, size limits, performance status, systemic disease control, and prior treatments when applicable. Trial eligibility (for example: ≤4 brain metastases, lesion size thresholds, Karnofsky score 80–100, ECOG 0–2) should be provided when using study-based rationale.
- Include trial-based inclusion criteria when citing studies (lesion counts, size limits, Gleason/PSA limits for prostate trials, ECOG/Karnofsky performance status).
- If request is based on a specific clinical trial, cite the trial and show the member meets key inclusion criteria.
Prior authorization requirements
Prior authorization requirements: submit relevant CPT/HCPCS and ICD-10 codes and supportive clinical documentation. Authorization may be required when requests fall outside routine, clearly specified coverage criteria (eg, non-standard sites, additional lesions, concurrent systemic therapies).
- Submit CPT/HCPCS/ICD-10 codes listed in the policy when requesting coverage.
- PA likely when request is for indications considered experimental/investigational or outside listed medically necessary criteria.
Evidence gaps may affect coverage
Evidence gaps noted by AHRQ and guideline reviews may affect coverage decisions. Many SBRT/SRS indications lack randomized comparative trials; some recommendations are based on level III (retrospective) evidence or single-arm studies. When evidence is limited, case-by-case review and additional documentation may be required.
- AHRQ technical brief identifies gaps and the need for randomized or concurrent-control studies.
- Lack of high-level evidence for many indications may prompt individualized coverage review.
Evidence limitations may affect coverage decisions
Evidence limitations (retrospective databases, single-arm series) can introduce confounders that affect interpretation and coverage decisions. When basing requests on such evidence, include rationale addressing limitations (eg, selection bias, unmeasured confounders, differences in systemic therapy availability).
- Retrospective analyses (eg, NCDB studies) may lack details on systemic therapy and cause of death—address these limitations in requests.
- When relying on level III evidence, provide clinical justification and any additional supporting literature.
No step therapy mandates specified
No mandatory step therapy (sequencing) requirements are specified in this policy excerpt. Standard surgical or other established treatment options should be considered prior to radiosurgical approaches when clinically appropriate (for example, surgery is preferred for operable stage I–II NSCLC).
- No step therapy mandates specified in this CPB.
- Consider conventional surgical options before radiosurgery when surgery is standard of care (eg, operable NSCLC).
Coding must be submitted
Providers should submit relevant CPT, HCPCS, and ICD-10 codes as listed in the policy when requesting coverage, along with all supporting clinical documentation. Incomplete coding or missing documentation may delay PA determinations.
- Include CPT/HCPCS/ICD-10 codes from the policy in the PA request.
- Provide complete clinical documentation to support medical necessity.
Suggested supporting documentation
Suggested supporting documentation: clinical indication, prior treatments, imaging (simulation and planning), target volumes, lesion counts and sizes, performance status, systemic disease status, and relevant trial citations or guideline references.
- Imaging used in trials: 4D-CT and FDG-PET/CT for simulation and target definition—attach images/reports when available.
- Document lesion counts, maximum diameters, margins, and motion-management measures (eg, rectal balloon for prostate SBRT) as applicable.
Supporting documentation for non-standard or evolving indications
For non-standard or evolving indications, submit clinical rationale and relevant literature to support the request. Case-by-case review will consider the balance of potential benefit and available evidence.
- Provide peer-reviewed literature or trial data when requesting coverage for experimental/less-established sites.
- Explain why conventional therapies are not appropriate or feasible for the member.
Imaging and trial inclusion documentation
Imaging and trial inclusion documentation: trials commonly used 4D-CT and FDG-PET/CT for simulation and target delineation; document imaging modality, fusion details, and target margins in the PA request.
- Attach simulation and planning imaging reports (eg, 4D-CT, FDG-PET/CT) and note fusion methods.
- Specify target definitions and margins used for planning as reported in supporting trials.
Clinical justification and performance status
Clinical justification should include performance status (eg, Karnofsky 80–100 or ECOG 0–2), evidence of controlled systemic disease when required, and prior therapy history. For brain metastases, limit to no more than 4 lesions unless further justification is provided.
- Document Karnofsky or ECOG performance status and systemic disease control.
- Provide prior treatment history and rationale for SRS/SBRT versus alternatives.
Not specified in these chunks
Not all provider-action items are specified in the extracted chunks; where a required operational detail is not listed (eg, explicit PA code lists or denial triggers), follow the general instruction to submit comprehensive clinical documentation and consult eviCore or payer administrative resources for specific PA submission rules.
- If a specific authorization rule or code requirement is not detailed here, contact eviCore/Aetna for submission requirements.
- This CPB is a summary and does not replace payer or eviCore operational procedures.
Surgery preferred for operable NSCLC
Surgical resection remains the preferred standard for operable stage I–II non-small-cell lung cancer (NSCLC); SBRT is an alternative when patients are medically inoperable or refuse surgery. Ensure multidisciplinary assessment and documentation when selecting SBRT over surgery.
- Document multidisciplinary assessment and reasons surgery is not appropriate if SBRT is requested for operable-stage disease.
- If citing comparative evidence, acknowledge limitations and reference trials or meta-analyses.
Consider standard surgical options before radiosurgery
Consider standard surgical or other established treatments prior to radiosurgery where applicable. Radiosurgical approaches should be selected when surgery is not feasible, contraindicated, or when evidence supports comparable outcomes in the specific clinical context.
- Prioritize conventional surgical options when they are standard of care.
- Provide documentation of contraindications to surgery when requesting radiosurgery instead.
Policy history and administrative note
Policy history and administrative notes: this Clinical Policy Bulletin contains a partial, general description of benefits and does not constitute a contract. The policy effective date is 1995-11-29; last review noted 02/08/2023 with next review 01/25/2024. For operational questions, consult payer resources.
- Effective date: 1995-11-29. Last review: 02/08/2023. Next review: 01/25/2024.
- CPB is informational and not a substitute for contractual benefit language.
Background and Evidence Summary
Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) deliver highly conformal, high-dose ionizing beams focused on a defined target while minimizing dose to adjacent normal tissues. Successful delivery relies on rigid or reproducible immobilization, high-resolution imaging for target delineation and planning (CT and MRI fusion, 4‑D CT for moving targets), and image guidance during treatment. Fractionation schemes vary by indication from single-fraction SRS to multi‑fraction SBRT or fractionated stereotactic radiotherapy when proximity to critical structures necessitates dose spreading.
Site-specific evidence summaries (supporting)
Site-specific evidence summaries referenced in background section as relevant to clinical positioning
Kopek et al (27 patients); careful patient selection and duodenal constraints advised.
Boike et al: groups of 15 patients with median follow-up up to 30 months.
Yamada et al series; longer follow-up required.
Herman et al and Buwenge et al findings.
Howington et al guideline and Zheng et al meta-analysis.
Indications with observational / systematic evidence (supporting)
Indications with observational / systematic evidence summarized here
Herman et al and Buwenge et al; evidence heterogeneous.
Singh et al and related pooled analyses.
Chen et al retrospective cohort.
Kobiela et al.
Guideline bodies and systematic reviewers have identified evidence gaps and the need for comparative studies — including randomized or concurrent-control trials — to fully establish comparative effectiveness of SBRT/SRS versus standard treatments. These limitations and the predominance of observational data in many indications may influence coverage determinations and underscore the role of eviCore guideline-based prior authorization for individual medical necessity assessments.
Definitions and Key Terms
Policy Dates and Revision History
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