CurrentCentenePolicy CP.MP.22

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

Medical necessity policy for up to five-session SBRT and SRS for specific clinical indications, governing Centene-affiliated health plans and affecting providers who request authorization for these therapies.

Policy Summary

PayerCentene

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

Policy CodePolicy CP.MP.22

Change TypeCriteria additions and coding updates

Effective Date

Next Review Date

Key ActionObtain prior authorization for SBRT/SRS courses (up to five fractions) using the referenced procedure codes when treating listed indications.

SourceLink

POLICY UPDATE CHANGES

Added I.K. 'Extracranial oligometastatic disease' with specific lesion and primary tumor criteria.

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

Added CPT code 61800 to coding list.

Added CPT-61800 and later added CPT G0563.

Reformatted criteria under II.C. and removed reference to 'if other positive clinical indications exist, such as stable systemic disease'.

Added extracranial oligometastatic disease criteria (1–3 lesions; specified primaries; controlled primary; no prior metastatic history).

Added indications for trigeminal neuralgia, select medically refractory epilepsy, movement disorders (Parkinson's, essential tremor), and hypothalamic hamartomas to align with ASTRO SRS model policy.

≤ 5sessions allowed

1-3

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Coverage Criteria for SBRT and SRS

Initial SBRT indications

Covered when ANY one of the following indications is met (up to five sessions):

SBRT indications: 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 application of 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 if delivering longer courses of external beam radiation therapy would present a documented hardship; I. Spinal tumors; J. Pancreatic adenocarcinoma meeting one of: (1) locally advanced disease without distant metastases, (2) combination therapy not feasible, (3) isolated local recurrence respecting normal organ tolerance; K. Extracranial oligometastatic disease meeting ALL of: (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.

Per policy section I.

Initial SRS indications

Covered when ANY one of the following indications is met (up to five sessions):

SRS indications: A. Cranial indications when unresectable due to deep intracranial location or patient unable to tolerate surgery, including: (1) inoperable small (≤3 cm) arteriovenous malformations; (2) benign tumors (meningiomas, pituitary adenomas, craniopharyngiomas, hemangiomas, pineal neoplasms); B. Small acoustic neuromas (≤3 cm) or enlarging neuromas in non-surgical candidates; C. Primary and/or metastatic brain malignancies when either: (1) Karnofsky Performance Status ≥40 and expected to return to ≥70 with treatment with 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 refractory to other treatments; F. Booster treatment for larger cranial or spinal lesions after initial EBRT or surgery (avoid when close to cranial nerves II and VIII if maximal dose >10 Gy); G. Relapse in previously irradiated cranial or spinal field requiring stereotactic precision; H. Spinal tumors; I. Refractory epileptic seizures in children when conventional surgery is technically difficult or excessively risky; J. Other select cranial non-neoplastic conditions (medically refractory epilepsy, movement disorders, hypothalamic hamartomas).

Per policy section II.

Oligometastatic disease criteria

Covered when documented indications in policy sections II (clinical criteria) and I (indications) are met as revised.

Extracranial oligometastatic disease (I.K): All of the following must be present: 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.1-3 lesions

Added in 01/23 revision and retained in subsequent annual reviews.

Additional covered indications (summary)

Other covered indications noted in revision history and aligned policies

Neurologic and movement disorder indications: Select SRS cases: trigeminal neuralgia, medically refractory epilepsy, movement disorders such as Parkinson's disease and essential tremor, and hypothalamic hamartomas (added to align with ASTRO SRS model policy).

Added in 01/24 revision to align with ASTRO guidance; wording later cleaned up.

Spinal tumors: 'Spinal tumors' listed as an indication for SBRT and SRS (updated from 'inoperable spinal tumors causing compression or intractable pain').

Terminology updated in 01/24 and 10/24 revisions.

Recurrent malignant disease - palliation: Recurrent malignant disease requiring palliation and/or palliative treatment for liver-related symptoms is an indicated use of SBRT.

Added in 01/23 revision and noted in revision history.

Requests for more than five sessions (fractions) of SBRT or SRS for indications other than those specifically listed in this policy are considered unsupported by the available evidence and are not recommended.

This clinical policy does not override specific member benefit provisions, exclusions, limitations, or state Medicaid requirements; when state Medicaid coverage provisions conflict with this policy, the state Medicaid provisions take precedence and should be consulted.

Courses of SBRT or SRS that exceed five fractions for indications beyond those enumerated in this policy lack sufficient evidence to support their use and therefore are not supported.

Language previously describing technologies or uses as "experimental/investigational" in criteria III has been replaced with descriptive wording in the revision history; the earlier NMN phrasing was removed and is not present in the same form in the current criteria.

Coding and Billing

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 cranial lesion(s) 1 session; multi-source Cobalt 60 based
77372	Radiation treatment delivery, SRS, complete course cranial lesion(s) 1 session; linear accelerator based
77373	Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, entire course not to exceed 5 fractions

1–10 of 12

1/2

Covered HCPCS CodesHCPCSCovered

G0339	Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course in one session or first session of fractionated treatment
G0340	Image guided robotic linear accelerator-based stereotactic radiosurgery, 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, entire course not to exceed 5 fractions

Updated/added codes (document revision log)CPT

61800	CPT code added (as listed in revision log)
G0563	CPT/HCPCS code added (noted in 10/24 revision)

Prostate SBRT fraction dose consideration

ThresholdRegimens with ≥ 6.5 Gy per fraction (ultrahypofractionation/SBRT) can be considered an alternative to conventionally fractionated regimens for localized prostate cancer at appropriately equipped centers; use in intermediate‑risk patients is encouraged within a clinical trial or multi‑institutional registry and for high‑risk disease is not suggested outside of a trial/registry.

Clinical contextASTRO/ASCO/AUA guidance grades ultrahypofractionation recommendations as conditional and emphasizes shared decision making and need for longer‑term data on late toxicity.

Implication for authorizationConsider prior/concurrent therapies (e.g., ADT) and risk group when evaluating SBRT ultrahypofractionated prostate regimens for medical necessity and authorization.

Oligometastatic lesion count

Allowed lesion count

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for SBRT and SRS courses. Providers must obtain prior authorization through the Health Plan's established processes before delivering SBRT/SRS. Requests for more than five fractions (sessions) of SBRT or SRS for indications other than those specifically listed in this policy are considered unsupported by the evidence and will generally not be approved.

Up to five fractions per course are medically necessary only for the listed indications; obtain prior authorization.
Requests >5 fractions for indications not listed are unsupported by evidence and may be denied.

Note

Review Coverage and CMS Determinations

Providers must review member benefit documents and applicable Medicare NCDs/LCDs prior to applying this clinical policy. For Medicare members, review all applicable NCDs, LCDs and Medicare Coverage Articles on the CMS website. For Medicaid members, state Medicaid coverage provisions take precedence when they conflict with this clinical policy. Coverage decisions remain subject to the terms, conditions, exclusions and limitations of the member's coverage documents.

Background

Stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) deliver highly conformal, high-dose radiation to precisely defined targets using stereotactic guidance and image localization. These treatments are typically completed in a short course of therapy, most commonly in one to five sessions (fractions), and require multidisciplinary planning and high-resolution stereotactic imaging to define the target and protect adjacent normal structures.

Definitions

SBRT

DefinitionStereotactic body radiation therapy (SBRT) delivering high‑dose, image‑guided radiation to extracranial targets in one to five sessions (fractions).

Typical targetsExtracranial sites such as lung, liver, and bone.

TechnologyPerformed using platforms such as LINAC, CyberKnife, Gamma Knife variants for extracranial use, and may incorporate robotics and real‑time imaging.

SRS

DefinitionStereotactic radiosurgery (SRS) for intracranial and spinal targets, typically performed in a single session but may be given in up to five sessions in select cases.

Typical indicationsCranial lesions (benign and malignant), arteriovenous malformations, select spinal tumors, and other focal intracranial conditions (e.g., trigeminal neuralgia, refractory epilepsy).

Revision History

2025-10annual_reviewLatest

Annual review reformatted criteria under II.C., removed wording 'if other positive clinical indications exist, such as stable systemic disease', and added CPT code G0563.

2024-10-01annual_review

Annual review updated I.I. and II.H. wording to 'spinal tumors', removed duplicate trigeminal neuralgia example from II.J., reformatted II.C., and added CPT code G0563.

2024-01-01annual_review