Prior review may be required per benefit booklet

Prior review (prior authorization) may be required per the individual member's benefit booklet.

Check member certificate for prior review requirements

Refer to the individual member’s benefit booklet for prior review/precertification requirements; prior review may be required per the member certificate.

Verify benefits, eligibility, and obtain required authorizations

Verify benefits and eligibility before applying these medical and payment guidelines; this policy is informational and is not an authorization — obtain any required authorizations per the member's contract.

Surgical resection preferred when feasible (context for sequencing)

Surgical resection is referenced as the preferred option for certain primary tumors when feasible; SBRT is considered when the patient is not a candidate for surgery or has refused surgery after informed consent.

• Example: Stage IA-IIA NSCLC — SBRT indicated when lesion ≤5 cm and patient is not a candidate for surgical resection or has refused surgery after informed consent (see coverage criteria).
• Example: Hepatocellular carcinoma and primary renal cell carcinoma — SBRT when disease is non-metastatic and patient is not a surgical candidate or refuses surgery.

Follow Billing/Coding guidance and confirm benefit applicability

Follow billing and coding guidance in the policy's Billing/Coding section; inclusion of a code does not guarantee reimbursement and applicability depends on the member’s benefits.

Be prepared to provide medical records when requested

BCBSNC may request medical records for determination of medical necessity; provide the documentation requested to support coverage decisions.

Confirm benefit applicability and prior review in member booklet

Refer to the member's benefit booklet for benefit applicability and prior review/prior authorization requirements; member benefits vary by plan and should be reviewed before applying this policy.

Include all specific clinical details when records are requested

When medical records are requested, include all specific information needed to make a medical necessity determination; letters or explanations alone are insufficient unless they contain all required details.

• Provide imaging reports, lesion counts and sizes, Karnofsky Performance Status, life expectancy estimates, prior treatments, and documentation of surgical candidacy or refusal where relevant.

Submit complete medical records when requested

When BCBSNC requests medical records for medical necessity determination, submit complete records — letters of support alone are not sufficient unless they include all specific information needed.

Investigational indications may be denied

SRS/SBRT provided for indications considered investigational by the policy (i.e., indications not listed as covered) may be denied.

• Examples include functional disorders other than trigeminal neuralgia and any extracranial SBRT indications not listed as covered.

Risk of denial if oligometastases criteria are not met

SBRT for oligometastases that does not meet the policy’s oligometastases criteria (e.g., more than six lesions, any lesion >6 cm, KPS <70, or life expectancy <6 months) may be denied as not medically necessary.

• Oligometastases coverage requires: ≤6 radiographically apparent lesions; none >6 cm; KPS ≥70; life expectancy ≥6 months.

Absence of requested information may lead to denial

BCBSNC may request medical records for determination of medical necessity; failure to provide the specific information requested may lead to denial.

Incomplete documentation may result in denial

BCBSNC may request medical records for determination of medical necessity; lack of the requested documentation (or incomplete documentation) may result in denial of coverage.