ModifiedAmbetter NevadaPolicy CP.MP.22

Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS)

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.MP.22 alerts

Get alerted when Policy CP.MP.22 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity criteria, indications, and coding guidance for up to five sessions of SBRT and SRS for members/enrollees of Ambetter Nevada (Centene-affiliated health plans). Affects radiation oncology providers requesting coverage.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedAmbetter NevadaPolicy CP.MP.22

Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS)

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.MP.22 alerts

Get alerted when Policy CP.MP.22 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerAmbetter Nevada

PolicyStereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS)

Policy CodePolicy CP.MP.22

Change TypeMaterial criteria additions and coding updates

Effective Date

Last ReviewSep 3, 2025

Next Review Date

Key ActionSubmit prior authorization for SBRT/SRS using the listed CPT/HCPCS codes and ensure clinical criteria and fraction limits (up to 5 sessions) are documented.

SourceLink

POLICY UPDATE CHANGES

Added I.F. 'Recurrent malignant disease requiring palliation and/or as palliative treatment for liver-related symptoms'.

Added I.I. 'Inoperable spinal tumors' as a criteria.

Added I.K. 'Extracranial oligometastatic disease' with 4 subcriteria (1-3 lesions, specified primaries, controlled primary tumor, no prior metastatic history).

Criteria II.C. updated to include Karnofsky and ECOG performance status and survival expectations aligned with ASTRO 2022 Model Policy for SRS.

Added CPT-61800

Added CPT code G0563

Reformatted criteria under II.C. and removed phrase about other positive clinical indications

≤5maximum sessions defined for SBRT/SRS coverage

1-3extracranial oligometastatic lesion count for coverage

KPS/ECOGperformance status requirement referenced for SRS

Multipleprocedure and delivery codes included

61800,G0563recently added/updated CPT codes

Coverage Criteria for SBRT and SRS

SBRT Medical Necessity

SBRT is medically necessary up to five sessions when ANY one of the following indications is met:

SBRT indications (I): A. Early stage non-small cell lung cancer (stage I–II, T1–T3, N0, M0) as an alternative to surgery; B. Acoustic neuroma; C. Localized malignant conditions in the body where highly precise high-dose radiotherapy is required, including tumors arising in or near previously irradiated regions; D. Recurrences of metastatic spine cancer after previous radiation; E. Hepatocellular carcinoma as an alternative to ablation/embolization or when those therapies have failed or are contraindicated; F. Recurrent malignant disease requiring palliation and/or as palliative treatment for liver-related symptoms; G. Low to intermediate risk localized prostate cancer; H. High risk prostate cancer when combined with androgen deprivation therapy when delivering longer courses of external beam radiation therapy would present a documented hardship; I. Spinal tumors; J. Pancreatic adenocarcinoma meeting one of the following: (1) locally advanced disease without distant metastases, (2) combination therapy not feasible, (3) isolated local recurrence respecting normal organ tolerance; K. Extracranial oligometastatic disease when ALL of the following are met: (1) one to three metastatic lesions involving the lungs, liver, or bone; (2) primary tumor is breast, colorectal, melanoma, non-small cell lung, prostate, renal cell, or sarcoma; (3) primary tumor is controlled; (4) no prior history of metastatic disease.up to 5 fractions

See policy text for subcriteria details

SRS Medical Necessity

SRS is medically necessary up to five sessions when ANY of the following are met:

SRS indications (II): A. Cranial indications when unresectable due to deep intracranial location or the member/enrollee cannot tolerate conventional operative intervention, including inoperable small (≤3 cm) arteriovenous malformations and specified benign tumors (meningiomas, pituitary adenomas, craniopharyngiomas, hemangiomas, pineal gland neoplasms); B. Small acoustic neuromas (≤3 cm) or enlarging neuromas in patients who are not candidates for surgery; C. Primary and/or metastatic brain malignancies when EITHER: (1) Karnofsky Performance Status ≥40 and expected to return to ≥70 with treatment and reasonable survival expectations, OR (2) ECOG Performance Status ≤3 and expected to return to ≤2 with treatment; D. Intracranial lesions where the patient refuses surgery; E. Severe, sustained trigeminal neuralgia not responsive to other treatments; F. Booster treatment for larger cranial or spinal lesions previously treated with external beam radiation therapy or surgery (avoid when in close proximity to cranial nerves II and VIII if maximal dose exceeds 10 Gy); G. Relapse in previously irradiated cranial or spinal field where stereotactic precision is required to avoid unacceptable vital tissue radiation; H. Spinal tumors; I. Refractory epileptic seizures in children when the lesion location makes conventional surgery technically difficult or excessively risky; J. Other cranial non-neoplastic conditions such as select movement disorders and hypothalamic hamartomas as aligned with specialty guidance.up to 5 fractions

Performance status and survival expectations required for some brain malignancy indications

Covered Indications (examples/highlights)

Policy includes specified indications and alignment with specialty guidance; examples added/updated in revisions

Selected covered indications (examples): Includes: recurrent malignant disease requiring palliation (including liver-related symptoms); spinal tumors (criteria expanded from inoperable spinal tumors to spinal tumors); extracranial oligometastatic disease with 1–3 lesions (lungs, liver, bone) when the primary is one of specified tumor types, primary tumor is controlled, and no prior history of metastatic disease; trigeminal neuralgia and select functional/epilepsy indications under SRS; performance-status and survival expectation language for brain malignancies updated to align with ASTRO 2022 Model Policy.

These examples reflect revisions and alignment with NCCN/ASTRO guidance as noted in the revision log

The policy states that there is insufficient evidence to support more than five sessions of stereotactic body radiation therapy (SBRT) or stereotactic radiosurgery (SRS) for indications not listed in the coverage criteria. Requests exceeding 5 fractions for indications outside the policy's specified indications are therefore not supported by the evidence base and would be beyond the policy limits.

During recent annual revisions the policy removed an internal ICD-10 code table and reformatted several examples. The revision log documents that the ICD-10 code table was removed and that examples were reviewed, reformatted, or deleted as part of those updates; providers should rely on submitted diagnosis coding that matches claims rules rather than an internal table that was removed from this policy.

Consistent with the policy statement, the use of SBRT or SRS beyond five fractions for indications not explicitly listed in the criteria is considered unsupported by available evidence. Therefore, care plans proposing more than 5 sessions for non‑listed indications do not meet medical necessity under this policy.

The revision history notes replacement of the term 'experimental/investigational' in Criteria III with more descriptive language. This edit standardizes terminology and uses explanatory wording in place of the prior label to describe services lacking sufficient evidence, rather than applying the 'experimental/investigational' designation.

Billing and Coding Guidance

Covered CPT CodesCPTCovered

61796	Stereotactic radiosurgery; 1 simple cranial lesion.
61797	Each additional cranial lesion, simple.
61798	Stereotactic radiosurgery; 1 complex cranial lesion.
61799	Each additional cranial lesion, complex.
61800	Application of stereotactic headframe for stereotactic radiosurgery.
63620	Stereotactic radiosurgery; 1 spinal lesion.
63621	Each additional spinal lesion.
77371	Radiation treatment delivery, SRS, complete course of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based.
77372	Radiation treatment delivery, SRS, complete course 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.

1–10 of 12

1/2

Covered HCPCS/G-CodesHCPCSCovered

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, per session, second through fifth sessions, maximum five sessions per course.
G0563	Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time position emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions.

Updated/Added CPT CodesCPT

61800	CPT-61800 (added to policy)
G0563	CPT G0563 (added to policy)

SBRT fraction size guidance (prostate example)

Threshold>= 6.5 Gy per fraction is considered ultrahypofractionation/SBRT for prostate per NCCN guidance

Clinical contextNCCN: ultrahypofractionated (>=6.5 Gy) SBRT may be offered for low- and intermediate-risk prostate cancer; recommended that intermediate-risk patients be treated on a clinical trial or multi-institutional registry

High-risk disease guidanceFor high-risk prostate cancer, ultrahypofractionation (SBRT) should not be offered outside of a trial or registry per guideline panel

Evidence noteGuideline panel graded recommendations for ultrahypofractionation as conditional due to limited long-term evidence; longer follow-up and prospective multi-institutional data are recommended

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) procedures identified by applicable CPT/HCPCS codes; providers must follow the Health Plan prior authorization process before scheduling treatment.

Affected codes include (but are not limited to): CPT 61796-61799, 61800, 63620-63621, 77371-77373, 77432, 77435; HCPCS G0339, G0340, G0563.
Follow Ambetter Nevada prior authorization submission requirements and timelines.
Ensure submitted authorization request includes clinical indication, prior treatments, and proposed fractionation (≤5 fractions unless otherwise supported).

Note

Coverage Conditional on Benefit Contract and State Rules

Coverage of SBRT/SRS is subject to the member's benefit contract, state regulations, and any applicable program-specific exclusions or limitations. For Medicaid members, state Medicaid provisions prevail if they conflict with this clinical policy.

Background and Rationale

Stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) are highly precise, high‑dose radiation techniques that deliver ablative doses to small, well‑defined targets while minimizing exposure to surrounding normal tissues. SBRT is typically used for extracranial sites and delivered over up to 1–5 fractions, whereas SRS is most commonly applied to intracranial and spinal targets (often a single session but up to 5 sessions in select cases). These modalities rely on stereotactic localization, multidisciplinary planning, and high‑resolution imaging (and may be delivered using a variety of platforms) to maximize tumor control and limit toxicity.

Definitions

Stereotactic — definition

TermStereotactic: localization of a target lesion relative to a fixed 3‑D reference system (rigid head frame, fixed bony landmarks, implanted fiducial markers, or similar) to enable highly accurate, image‑guided procedures

PurposeAllows convergence of multiple non‑parallel radiation beams to a sharply defined target to spare surrounding tissue

TechnologiesCommon platforms include Gamma Knife, LINAC, CyberKnife, and proton or heavy‑charged‑particle systems; robotics and real‑time imaging may be used to enhance precision

SBRT — definition

DefinitionSBRT (stereotactic body radiation therapy): stereotactic radiation therapy used to treat extracranial sites, delivered in 1 to 5 fractions

TargetingDelivers high‑dose, highly precise radiation to small extracranial targets while minimizing dose to surrounding tissue

Revision History and Policy Changes

01/23criteria_added

Added I.F. 'Recurrent malignant disease requiring palliation and/or as palliative treatment for liver-related symptoms' and I.I. 'Inoperable spinal tumors'; added I.K. 'Extracranial oligometastatic disease' with subcriteria (1–3 lesions, specified primaries, controlled primary tumor, no prior metastatic history).

05/13codes_added

Added CPT-61800 and updated codes and disclaimers for HIX products during annual review; replaced 'member' with 'member/enrollee' throughout the document.

10/24codes_added

Policy Summary

PayerAmbetter Nevada

PolicyStereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS)

Policy CodePolicy CP.MP.22

Change TypeMaterial criteria additions and coding updates

Effective Date

Last ReviewSep 3, 2025

Next Review Date

Key ActionSubmit prior authorization for SBRT/SRS using the listed CPT/HCPCS codes and ensure clinical criteria and fraction limits (up to 5 sessions) are documented.

SourceLink

On This Page

Verify member eligibility and benefit coverage prior to service.
Adhere to any state-specific rules or limits (e.g., Medicaid) that supersede this policy.

Documentation Required

Procedure Planning and Documentation

Procedure planning must document multidisciplinary team involvement and use high-resolution stereotactic imaging to define targets and safely deliver SBRT/SRS.

Document involvement of relevant specialists (e.g., surgeon, radiation oncologist, radiologist, medical physicist, dosimetrist, radiation therapist).
Include high-resolution stereotactic imaging and target delineation, treatment plan, dose per fraction, total fractions, and organ-at-risk constraints.
If treating previously irradiated regions, include prior radiation records and cumulative dose considerations.

Note

Review Medicare / State Coverage Guidance

Providers should review applicable Medicare National and Local Coverage Determinations (NCDs/LCDs) and Medicare Coverage Articles prior to applying this policy to Medicare members.

Refer to CMS (http://www.cms.gov) for current NCDs, LCDs and coverage articles.
Ensure consistency with Medicare coverage guidance when managing Medicare members.

Note

Prior Local Therapy Considerations

SBRT may be considered following prior local therapy for select indications (e.g., hepatocellular carcinoma, pancreatic adenocarcinoma, prostate cancer, recurrent/previously irradiated spine metastases) when clinically appropriate and supported by documentation.

Document prior local therapies and rationale for SBRT as alternative or salvage treatment.
For HCC: consider SBRT when ablation/embolization have failed or are contraindicated, and when extrahepatic disease is absent or minimal.
For pancreatic adenocarcinoma: SBRT is an option at experienced centers for select locally advanced disease or isolated local recurrence; avoid if direct bowel/stomach invasion is present.
For prostate cancer: SBRT may be used in low-to-intermediate risk disease or high-risk with ADT when longer EBRT courses present documented hardship.

Note

(Reserved)

This block preserved as a placeholder per inventory.

Platforms and deliveryPerformed on multiple delivery systems (LINAC, CyberKnife, proton beam, etc.) with image guidance and stereotactic localization

SRS — definition

DefinitionSRS (stereotactic radiosurgery): stereotactic radiation therapy for intracranial and spinal targets, typically performed in a single session but may be delivered in up to 5 sessions in select cases

IndicationsUsed for small intracranial lesions, selected benign tumors, AV malformations, and spinal tumors where high precision is required

Fractionation noteAlthough typically single‑session, fractionated SRS (up to 5 sessions) is acceptable in limited circumstances per policy

Extracranial oligometastatic disease — definition

Lesion countExtracranial oligometastatic disease is defined as 1–3 metastatic lesions in lungs, liver, or bone

Allowed primariesPrimary tumor sites include breast, colorectal, melanoma, non‑small cell lung, prostate, renal cell, or sarcoma

Additional requirementsPrimary tumor must be controlled and there must be no prior history of metastatic disease

Added HCPCS/CPT G0563 and reformatted criteria under II.C. (removed phrase about other positive clinical indications such as stable systemic disease).

10/25codes_addedLatest

Finalized annual review updates that added CPT G0563 and reformatted II.C.; references reviewed and updated.