CurrentCentenePolicy MC.CP.MP.22

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

Medical necessity criteria for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) for Medicare health plans affiliated with Centene, describing covered indications, not medically necessary situations, and coding guidance.

Policy Summary

PayerCentene

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

Policy CodePolicy MC.CP.MP.22

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for SRS/SBRT services billed with the listed CPT and HCPCS codes and document medical necessity per policy criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1-5SBRT fractions allowed per course (maximum)

KPS ≥40KPS threshold

ECOG ≤3ECOG threshold

Codes listedCodes referenced

Coverage Criteria for SRS and SBRT

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inv-01: SRS - Medically Necessary

SRS is medically necessary when ANY of the following are met:

SRS Indications: Primary central nervous system malignancies (generally used as boost or salvage therapy for lesions <5 cm); primary and secondary tumors of the brain or spine parenchyma, meninges/dura, or immediately adjacent bony structures; benign brain and spinal tumors (e.g., meningiomas, acoustic neuromas, schwannomas, pituitary adenomas, pineocytomas, craniopharyngiomas, glomus tumors, hemangioblastomas); cranial arteriovenous malformations, cavernous malformations, or hemangiomas; other cranial non‑neoplastic conditions such as trigeminal neuralgia and select medically refractory epilepsy; as a boost for larger cranial or spinal lesions after external beam RT or surgery; metastatic brain or spine lesions when systemic disease is stable and performance status is acceptable (Karnofsky Performance Status ≥40 or expected to return to ≥70, or ECOG ≤3 or expected to return to ≤2) with otherwise reasonable survival expectations; relapse in a previously irradiated cranial or spinal field where additional stereotactic precision is required to avoid unacceptable radiation to vital tissues.

See Tables 1 and 2 for performance status definitions

inv-02: SRS - Not Medically Necessary

SRS is not medically necessary when ANY of the following are present:

SRS Not Medically Necessary: Treatment for indications other than a severe symptom or a serious threat to life or critical functions; treatment unlikely to result in functional improvement or clinically meaningful disease stabilization not otherwise achievable; widespread cerebral or extracranial metastases with limited life expectancy unlikely to gain clinical benefit; poor performance status (Karnofsky Performance Status <40 or ECOG >3); cobalt‑60 pallidotomy.

inv-03: SBRT - Medically Necessary

SBRT is medically necessary when ANY of the following are met:

SBRT Indications: Primary tumors and metastases to lung, liver, kidney, adrenal gland, or pancreas; treatment of pelvic and head and neck tumors that have recurred after primary irradiation; clinically localized, low‑ to intermediate‑risk prostate cancer; recurrence in or near previously irradiated regions of any body site or internal organ when both (1) a high level of precision and accuracy or a high dose per fraction is required to minimize risk to surrounding normal tissues, and (2) conventional methods are not appropriate or safe for the particular patient (medical records must describe the specific circumstances).<=5 fractions per course where applicable

SBRT may be delivered in 1–5 sessions; each fraction requires identical precision and image guidance

inv-04: SBRT - Not Medically Necessary

SBRT is not medically necessary when ANY of the following are present:

SBRT Not Medically Necessary: As primary treatment of lesions of bone, breast, uterus, ovary, and other internal organs not otherwise specified as covered; treatment unlikely to result in clinical cancer control and/or functional improvement; tumor burden cannot be completely targeted with acceptable risk to critical normal structures; poor performance status (Karnofsky Performance Status <40 or ECOG ≥3); recurrent (other than pelvic and head/neck) or metastatic disease that could be treated by conventional methods unless records document why conventional methods are inappropriate or unsafe; any course of radiation treatment extending beyond five fractions (such courses are not considered SBRT).

SBRT is intended to represent a complete course delivered in an accelerated timeframe and not as a boost following conventional fractionation

SBRT is defined in this policy as a complete course of stereotactic body radiation therapy delivered in an accelerated timeframe and therefore is not considered SBRT if any course of radiation treatment extends beyond five fractions. The policy explicitly states that SBRT should not be used as a boost following conventional fractionation, because the intent of SBRT is to "maximize the potency of the radiotherapy by completing an entire course of treatment within an extremely accelerated time frame."

Separately, the policy identifies cobalt-60 pallidotomy as a specific procedure that is considered not medically necessary under the SRS/SBRT policy.

Performance status is a required consideration for SRS and SBRT coverage decisions. The policy specifies that SRS or SBRT is considered not medically necessary for members with poor performance status defined as Karnofsky Performance Status (KPS) less than 40 or ECOG Performance Status greater than 3, and similarly flags SBRT as not medically necessary when KPS is 40 or ECOG is 3 or worse.

The policy further explains that treatments are unlikely to be approved when functional improvement or clinically meaningful disease stabilization is not expected given the member’s performance status or limited life expectancy; documentation should support reasonable expectation of benefit or an expectation that performance status will improve to acceptable thresholds when applicable.

Coding and Treatment Limits

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, stereotactic radiosurgery (SRS), complete course cranial lesion(s) 1 session; cobalt-60 based
77372	Radiation treatment delivery, stereotactic radiosurgery (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 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

inv-09: Maximum SBRT fractions

Maximum fractions per SBRT courseEntire SBRT treatment course must not exceed five fractions (sessions)

Definition of exceeding fraction limitAny course of radiation treatment extending beyond five fractions is not considered SBRT

RationaleSBRT is intended as a complete, accelerated course to maximize radiotherapy potency and not as a boost following conventional fractionation

Provider Requirements, Prior Authorization, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for SRS/SBRT services. Providers must submit authorization requests before treatment and include documentation supporting medical necessity, especially for re-irradiation near previously irradiated regions.

Affected CPT/HCPCS: 61796–61799, 61800, 63620–63621, 77371–77373, 77432, 77435, G0339, G0340
Authorization must indicate planned fractionation (SBRT = entire course ≤5 fractions) and treatment site

Documentation Required

Documentation Required for Re-irradiation

Documentation — Required clinical rationale for re-irradiation: When SBRT is planned for recurrence in or near a previously irradiated region, medical records must describe why conventional radiation is not appropriate or safe and demonstrate that a high level of precision/accuracy or a high dose per fraction is indicated to minimize risk to surrounding normal tissues.

Explicit description of prior radiation (dates, doses, fields) and interval since prior therapy
Rationale why conventional methods are unsuitable for this member
Treatment planning details supporting precision (imaging, immobilization, dose per fraction, organs-at-risk constraints)

Denial Risk

Denial Triggers / Clinical Exclusions

Provider Action: Denial Triggers — Services may be denied if criteria indicating lack of clinical benefit or safety concerns are present.

Treatment for indications other than severe symptoms or a serious threat to life/critical functions
Treatment unlikely to yield functional improvement or meaningful disease stabilization
Widespread metastases with limited life expectancy unlikely to gain benefit within remaining life
Poor performance status (Karnofsky <40 or ECOG ≥3)
Tumor burden cannot be targeted with acceptable risk to critical normal structures
Planned course exceeds 5 fractions (SBRT defined as ≤5 fractions)

Definitions

inv-15: Stereotactic radiosurgery (SRS)

DefinitionStereotactic radiosurgery (SRS) is a method of delivering highly focused radiation to intracranial and spinal targets using convergent beams and stereotactic localization for high anatomic accuracy

Typical session numberTypically delivered in a single session (single fraction)

Guidance/immobilizationUses rigid stereotactic guiding devices, frames, implanted fiducials, or other immobilization and stereotactic-guidance systems to ensure precision

Indications (site focus)Primarily used for intracranial and spinal lesions rather than extra-cranial sites

inv-16: Stereotactic body radiation therapy (SBRT)

DefinitionStereotactic body radiation therapy (SBRT) is a method of delivering highly focused radiation to extra-cranial sites with stereotactic localization and techniques to manage organ and patient motion

Typical fractionsUsually completed in one to five fractions (sessions)

Image guidance requirementAll SBRT is performed with at least one form of image guidance to confirm positioning and tumor localization prior to each fraction

Motion management and immobilizationRequires reliable immobilization or repositioning and often methods to decrease or account for organ motion (e.g., respiratory gating)

OpenPayer

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

Coverage Criteria for SRS and SBRT

Coding and Treatment Limits

Provider Requirements, Prior Authorization, and Denial Triggers

Definitions

Background