Prior Authorization Required

Prior authorization is required for stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) courses described in this policy. Requests should follow the Health Plan’s established prior authorization procedures and be submitted before services are rendered when possible. Courses of treatment up to five fractions/sessions will be reviewed against the policy criteria; requests for more than five sessions for indications not specifically enumerated in the policy are not supported by the evidence summarized in this policy and may be denied.

• Providers must obtain authorization per the Health Plan’s procedures prior to initiation of treatment when required.
• Requests exceeding five fractions/sessions should include supporting clinical rationale and are at increased risk for denial.

Documentation Expectations

Documentation submitted with authorization requests and claims must demonstrate how the requested SBRT/SRS meets the policy indications and clinical criteria. Include relevant history, imaging reports, pathology, prior treatment records (including prior radiation fields and doses), performance status (Karnofsky or ECOG), tumor size/location details, and a treatment plan specifying dose per fraction, total dose, and modality (e.g., linac-based, Gamma Knife, robotic). For recurrent disease or retreatment, provide prior radiation dosimetry and justification for stereotactic approach.

• Provide imaging and reports that show lesion size, location relative to critical structures, and absence or extent of metastatic disease as applicable.
• Include documentation of multidisciplinary discussion or tumor board review when available, and clinical rationale when SBRT/SRS is used as an alternative to other therapies.

Coding and Billing Guidance

Providers must follow current professional coding guidance when submitting claims. CPT, HCPCS and other codes listed in this policy are informational and not exhaustive. Inclusion or exclusion of codes here does not guarantee coverage. Verify and use the most up-to-date CPT/HCPCS descriptors and modifiers, and append appropriate modifiers indicating laterality, multiple procedures, or staged treatments as required by coding rules.

• Reference current CPT guidance prior to claim submission; codes in the policy (e.g., 77373, 77435, 61796-61800 series, 63620-63621, G0339-G0340, G0563) are examples and not guaranteed to be all-inclusive.
• When billing for fractionated courses, ensure the course-level vs per-fraction codes are applied correctly and that image-guidance or robotic delivery descriptors are supported by documentation.

Consideration of Alternative Therapies

Consideration should be given to alternative therapies and sequencing of care. For some indications (for example early-stage non-small cell lung cancer, hepatocellular carcinoma, pancreatic cancer, and prostate cancer) SBRT/SRS may be offered as an alternative to surgery, ablation, embolization, or conventionally fractionated external beam radiation therapy when clinically appropriate. Document why SBRT/SRS is preferred or necessary (e.g., medical inoperability, prior therapies failed or contraindicated, patient refusal of surgery, or to provide palliation).

• When SBRT/SRS is used as an alternative, provide documentation of contraindications to or failure of other standard therapies, or evidence of multidisciplinary consensus supporting the selected approach.
• For pancreatic SBRT, consider referral to or treatment at high-volume centers with image-guided capability; avoid SBRT when direct invasion of bowel or stomach is present on imaging.

Denial Risk and Appeals

Coverage determinations are subject to all terms, conditions, exclusions, and limitations of the member’s benefit plan. Failure to provide required documentation, use of incorrect or outdated codes, or provision of services outside the policy criteria may result in denial. Providers may appeal adverse determinations per the Health Plan’s established appeal processes.

• Denials commonly result from insufficient documentation of indication, lack of prior authorization when required, requests for treatment courses exceeding five fractions without compelling evidence, or billing with inappropriate codes/modifiers.
• Review applicable state Medicaid, Medicare NCDs/LCDs, and the member’s benefit contract; when conflicts exist, state Medicaid provisions or Medicare determinations take precedence for respective members.