ModifiedBlue Cross Blue Shield - LouisianaPolicy 00045

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

Defines coverage eligibility for SRS and SBRT across multiple indications (cranial, spine, bone metastases, breast, other malignancies) for members of Blue Cross and Blue Shield of Louisiana and HMO Louisiana.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

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

Policy CodePolicy 00045

Change TypeCoverage criteria revised and expanded (fractionation limits, oligometastatic additions, pancreatic reorganization, HCC sequencing)

Effective DateMar 25, 2002

Next Review DateJan 1, 2027

Key ActionObtain prior authorization to verify member benefits and that site-specific selection criteria and prior radiation history meet coverage requirements.

SourceLink

POLICY UPDATE CHANGES

Clarified that the maximum number of fractions for SBRT is 5 in both NSCLC and SCLC.

Added coverage with criteria for SBRT for extra-cranial oligoprogressive disease and included adrenal metastases within oligometastatic coverage (1-3 lesions).

Moved pancreatic cancer criteria into a new 'Pancreatic Cancer' coverage section with specific indications for locally advanced/recurrent disease without distant metastasis or to treat a previously irradiated field.

For hepatocellular carcinoma (HCC), removed the phrase requiring exhaustion of other therapy options for palliative SBRT—sequencing language loosened.

5Max SBRT fractions (lung)

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