CurrentCommunity Health Plan WashingtonPolicy MC.CP.MP.22

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 in MAC jurisdictions lacking full CMS/MAC coverage criteria; includes indications, non-covered scenarios, performance-status thresholds, coding guidance, and procedure components.

Policy Summary

PayerCommunity Health Plan Washington

PolicyMC.CP.MP.22 Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

Policy CodePolicy MC.CP.MP.22

Change TypeAdded clinical criteria and coding updates (editorial clarifications)

Effective Date

Next Review Date

Key ActionDocument medical rationale when conventional methods are not appropriate and record Karnofsky and/or ECOG performance status to demonstrate eligibility.

SourceLink

POLICY UPDATE CHANGES

Added criteria III.E.1-III.E.4 defining extracranial oligometastatic disease (1-3 lesions; specified primary tumors; controlled primary; no prior metastatic history).

Added CPT codes 61796-61800, 63620-63621, 77371-77372, 77432, and later G0563 to policy coding list.

Policy intention noted as for use by Medicare health plans affiliated with Centene in MAC jurisdictions lacking full CMS/MAC coverage criteria.

1-3Allowed extracranial oligometastatic lesions

<=5SBRT fraction limit

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Performance status scales referenced

MultipleCovered indications

Coverage Summary

This policy covers medical necessity criteria for Stereotactic Radiation Therapy (SRS and SBRT) for Medicare health plans affiliated with Centene Corporation in MAC jurisdictions lacking full CMS/MAC coverage criteria. Policy number MC.CP.MP.22. Status: CURRENT. Last review/Revision Date: 12/25 (last_review: 2025-12-25). Effective date: referenced as the Health Plan–determined effective date; see policy for plan-specific effective posting. Subject: Stereotactic Radiation Therapy (SRS and SBRT).

Key thresholds (quick reference)

SBRT fraction limit<= 5 fractions per course

Lesion size for SRS boost/salvage< 5 cm

Karnofsky Performance Status (KPS) thresholdMedically acceptable if >= 40; not necessary if < 40 (expectation: may return to 70 with treatment)

ECOG Performance Status thresholdMedically acceptable if <= 3; not necessary if > 3 (may require expected return to <=2 for some indications)

Extracranial oligometastatic lesion count1-3 lesions (lungs, liver, or bone)

SRS — Medical Necessity Criteria

SBRT — Medical Necessity Criteria

Coding

SRS CPT codes (informational)CPT

61796	Stereotactic radiosurgery; 1 simple cranial lesion
61797	Each additional cranial lesion, simple (list separately)
61798	Stereotactic radiosurgery; 1 complex cranial lesion
61799	Each additional cranial lesion, complex (list separately)
61800	Application of stereotactic headframe for stereotactic radiosurgery (list separately)
63620	Stereotactic radiosurgery; 1 spinal lesion
63621	Each additional spinal lesion (list separately)

Radiation delivery and management CPT/HCPCS codes (informational)mixed

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
77432	Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)
77435	SBRT treatment management, per treatment course, to 1 or more lesions, entire course not to exceed 5 fractions
G0339	Image-guided robotic linear accelerator-based SRS, complete course in one session or first session of fractionated treatment
G0340	Image-guided robotic linear accelerator-based SRS, fractionated treatment, per session, second through fifth sessions (max five sessions per course)
G0563	SBRT treatment delivery, per fraction including image guidance and real-time position emission-based delivery adjustments, entire course not to exceed 5 fractions

Provider Actions & Billing Rules

Documentation Required

Document medical rationale for SBRT when conventional methods are not appropriate

When SBRT is used because conventional methods are not appropriate or safe for the member/enrollee, the medical record must describe the specific circumstances that justify SBRT as the chosen approach. Document the clinical rationale, why conventional radiation or other treatments are contraindicated or unsafe, and how SBRT’s high precision or dose-per-fraction benefits apply to this case.

Describe why conventional methods are not appropriate or safe for this patient.
Explain the high precision or high dose-per-fraction need and how SBRT addresses it.
Include pertinent clinical details in the record (tumor location, prior radiation, comorbidities, anatomic constraints).

Documentation Required

Performance status documentation required

Performance status must be documented to demonstrate eligibility. Acceptable thresholds referenced in the policy: Karnofsky Performance Status (KPS) of 40 or greater (or expected to return to 70 or greater with treatment) and/or an ECOG Performance Status of 3 or less (or expected to return to 2 or less with treatment). Examples of KPS and ECOG score descriptors are provided in Tables 1 and 2.

Background and Evidence

Background: SRS is used to treat intracranial and spinal targets, typically performed in a single session with rigid immobilization or stereotactic guidance; SBRT is used to treat extracranial sites and is delivered in 1-5 fractions with required image guidance and measures to account for organ motion (e.g., respiratory gating), and each fraction requires identical precision, localization and image guidance. (CMS LCD L35076 and supporting ASTRO/NCCN guidance are the primary sources cited.)

Treatment components: SRS/SBRT procedures include planning, position stabilization (frame or frameless immobilization), imaging for localization (CT, MRI, angiography, PET, etc.), computer-assisted tumor localization (image guidance), detailed treatment planning (isocenters, arcs/angles, beams, beam size/weight), isodose distributions and dose prescription/calculation, setup and accuracy verification/testing, simulation of prescribed arcs/portals, and radiation treatment delivery.

Fractionation and delivery rationale: SBRT is typically delivered in one to five sessions and is limited to an entire course not to exceed 5 fractions (any course beyond five fractions is not considered SBRT for coverage purposes). SBRT requires image guidance for each fraction and appropriate motion management for extracranial sites to minimize exposure to adjacent structures. SRS is typically a single-session treatment with rigid stereotactic guidance and immobilization.

Rationale and sources: The criteria and components are drawn from CMS LCD L35076 (and related LCA A56874) and are supported by professional society guidance from ASTRO and NCCN, which inform indications, fractionation limits, required image guidance, and performance-status requirements for medically necessary use.

Medicare Determinations

Name	Number	Effective / Revised Date
Stereotactic radiation therapy: SRS and SBRT	L35076	2015-10-01 (revised 2020-04-01)

Revision History

08/23added

Added criteria III.E.1–III.E.4 defining extracranial oligometastatic disease: one to three metastatic lesions involving the lungs, liver or bone; primary tumor types specified (breast, colorectal, melanoma, non-small cell lung, prostate, renal cell or sarcoma); primary tumor is controlled; no prior history of metastatic disease.

08/23added

Added criteria III.F (Acoustic neuroma) and III.G (Spinal tumors) as medically necessary indications for SBRT.

10/24coding_added

Policy Summary

PayerCommunity Health Plan Washington

PolicyMC.CP.MP.22 Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

Policy CodePolicy MC.CP.MP.22

Change TypeAdded clinical criteria and coding updates (editorial clarifications)

Effective Date

Next Review Date

Key ActionDocument medical rationale when conventional methods are not appropriate and record Karnofsky and/or ECOG performance status to demonstrate eligibility.

SourceLink

On This Page

Record the scale name(s) used: Karnofsky Performance Status (KPS) and/or ECOG Performance Status.
If KPS < 40 or ECOG > 3, SBRT/SRS is described as not medically necessary per the policy unless expected improvement is documented.
If claiming expected improvement, document the clinical basis for expectation (e.g., reversible condition, planned intervention).

Billing Rule

SBRT fraction limit

SBRT treatment delivery codes and the policy rule that SBRT courses must not exceed five fractions. Any radiation course extending beyond five fractions is not considered SBRT for coverage purposes.

77373
G0563
G0340
Coverage rule: Any course of radiation treatment extending beyond five fractions (sessions) is not considered SBRT.

Billing Rule

List separately codes for additional lesions

When multiple cranial or spinal lesions are treated, report the additional-lesion CPT codes separately in addition to the primary procedure code.

61797
61799
63621
Instruction: Report each additional cranial or spinal lesion using the listed 'each additional lesion' CPT codes separately in addition to the primary procedure code.

CMS LCD L35076 and related LCA A56874; supported by ASTRO and NCCN

SRS: Stereotactic radiosurgery used to treat intracranial and spinal targets, typically in a single session with rigid immobilization or stereotactic-guidance.

SBRT: Stereotactic body radiation therapy used to treat extracranial sites, delivered in 1-5 fractions with image guidance and motion management; any course extending beyond five fractions is not considered SBRT for coverage purposes.

Karnofsky Performance Status (KPS): Scale measuring functional status where higher scores indicate better function; examples provided in Table 1 (e.g., 40 = disabled; requires special care and assistance; higher scores indicate better functional status).

ECOG Performance Status: Eastern Cooperative Oncology Group scale measuring functional status where lower scores indicate better function; examples provided in Table 2 (e.g., 3 = capable of only limited self-care, confined to bed or chair >50% of waking hours).

Added CPT codes 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, and 77432 to policy coding list (coding implications updated).

10/25coding_added

Added HCPCS/CPT code G0563 to policy coding list (SBRT per-fraction delivery including image guidance and real-time position emission-based adjustments).

12/25clarifiedLatest

Policy description clarified to note the policy is intended for use by Medicare health plans affiliated with Centene Corporation in MAC jurisdictions lacking full CMS/MAC coverage criteria.