CurrentCommunity Health Plan WashingtonPolicy MC.CP.MP.22

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

Defines 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 covered indications, not-medically-necessary indications, procedure components, and CPT/HCPCS coding guidance.

Policy Summary

PayerCommunity Health Plan Washington

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

Policy CodePolicy MC.CP.MP.22

Change TypeAddedRevisedCoding update

Effective Date

Next Review Date

Key ActionDocument Karnofsky and/or ECOG performance status and justify in the medical record why conventional methods are not appropriate when using SBRT for recurrence in or near previously irradiated regions.

SourceLink

POLICY UPDATE CHANGES

Added criteria III.E.1-III.E.4 for extracranial oligometastatic disease (one to three metastatic lesions; specified primary tumors; controlled primary tumor; no prior metastatic history).

Clarification in policy description.

Added CPT/HCPCS code G0563 to policy.

2-5SBRT fractions per course

>=40Karnofsky threshold (eligible)

<=3

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Coverage Summary

Overview: This policy (Subject: Stereotactic Radiation Therapy (SRS and SBRT); Policy Number: MC.CP.MP.22) defines medical necessity criteria for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) for Medicare health plans affiliated with Centene in Medicare Administrative Contractor (MAC) jurisdictions that lack full CMS/MAC coverage criteria. The policy status is CURRENT with a documented last review date of 2025-12-25.

Definitions and scope: SRS is defined as typically a single-session, highly precise intracranial or spinal radiation treatment used for intra-cranial and spinal targets. SBRT denotes extracranial stereotactic radiation delivered with at least one form of image guidance and is typically delivered in 1 to 5 fractions. The policy emphasizes high precision target localization and the routine use of image guidance for each fraction or session.

Treatment course and components: SRS is generally a single session; SBRT may be delivered in one to five sessions (fractions) and any course extending beyond five fractions is not considered SBRT. Key components of planning and delivery include position stabilization (frame or frameless), imaging for localization (CT, MRI, angiography, PET, etc.), computer-assisted tumor localization (image guidance), treatment planning (isocenters, beams/arcs), isodose distributions and dose prescription, setup and accuracy verification, simulation, and radiation treatment delivery.

Policy use and coding note: The policy criteria are sourced from CMS LCD L35076 and are supported by ASTRO and NCCN; it is intended for use by Medicare Centene-affiliated plans in MAC jurisdictions without full CMS/MAC coverage criteria. CPT/HCPCS coding information is included for informational purposes and does not guarantee coverage; providers should reference up-to-date coding guidance.

Key thresholds and statistics

SBRT fractions per course1 to 5 fractions (entire course not to exceed 5)

SBRT common course range (stats)2-5 fractions per course

Karnofsky Performance Status threshold>= 40 (eligible); < 40 considered poor performance / not medically necessary

ECOG Performance Status threshold<= 3 (eligible); ECOG 3 or worse considered poor performance / not medically necessary

Oligometastatic lesion count (extracranial)1-3 metastatic lesions (lungs, liver, or bone)

Lesion size threshold for SRS (boost/salvage)Lesions < 5 cm

SRS — Medically Necessary / Not Medically Necessary

SBRT — Medically Necessary / Not Medically Necessary

CPT / HCPCS Codes

SRS / SBRT CPT / HCPCS codes referenced (informational)mixed

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

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Provider Actions & Billing Rules

Documentation Required

Document rationale when conventional methods not appropriate

Document why conventional radiation methods are not appropriate or safe when using SBRT for recurrence in or near previously irradiated regions; the medical record must describe the specific circumstances.

Medical records must describe specific circumstances why conventional methods are not appropriate or safe for recurrence in or near previously irradiated regions.

Documentation Required

Performance status documentation required

Document the patient’s performance status (Karnofsky and/or ECOG) to support eligibility for SRS/SBRT per policy thresholds.

Karnofsky Performance Status ≥ 40
ECOG Performance Status ≤ 3

Background, Evidence & Definitions

Background and basis: This policy is based on the Centers for Medicare and Medicaid Services Local Coverage Determination L35076 (Stereotactic Radiation Therapy: SRS and SBRT) and is explicitly supported by guideline sources from the American Society for Radiation Oncology (ASTRO) and the National Comprehensive Cancer Network (NCCN). The policy statement identifies benefits (targeting tumors while limiting exposure to nearby organs/tissues and enabling near-surgical precision without surgery) and acknowledges rare long-term risks from radiation exposure.

Description of SRS and SBRT components and delivery: Stereotactic procedures use highly focused convergent beams and a three-dimensional reference system for high anatomic accuracy and precision. SRS is used for intracranial and spinal targets (typically single-session) and SBRT is used for extracranial sites where organ and patient motion must be managed. All SBRT is performed with at least one form of image guidance prior to each fraction. SRS/SBRT procedures include planning, position stabilization (frame or frameless), localization imaging, computer-assisted tumor localization (image guidance), detailed treatment planning (isocenters, arcs, beam geometry), isodose distribution and dose prescription, setup and accuracy verification, simulation of arcs/portals, and the radiation treatment delivery.

Coding and updates: The policy includes referenced CPT/HCPCS codes for SRS and SBRT for informational use (examples include codes for stereotactic radiosurgery, spinal SRS, SRS/SBRT delivery and management, and image-guided robotic delivery). Revision history notes material additions of extracranial oligometastatic disease criteria (one to three metastatic lesions; specified primary tumors; controlled primary tumor; no prior metastatic history), additions of indications such as acoustic neuroma and spinal tumors, and coding updates including the addition of multiple CPT codes and HCPCS code G0563 in recent revisions.

Reference	Detail
Primary external reference	LCD L35076 and Medicare Coverage Article A56874 (Primary external references cited in policy).
Guideline support	Supported by ASTRO model policies and NCCN guidelines (policy references ASTRO and NCCN).

Term	Definition
SRS	Stereotactic radiosurgery — typically a single-session, highly precise intracranial or spinal radiation treatment.
SBRT	Stereotactic body radiation therapy — extracranial stereotactic radiation, performed with at least one form of image guidance and typically delivered in one to five fractions.
Karnofsky Performance Status	Scale ranging 0-100 where higher values indicate better performance; policy notes >=40 considered eligible and table describes scale descriptors (100 to 0).
ECOG Performance Status	Scale 0-5 where lower values indicate better performance; policy notes <=3 considered eligible and table describes scale descriptors (0 to 5).

Medicare Determinations

Name	Number	Effective (revised)
Stereotactic Radiation Therapy: SRS and SBRT	L35076	Published October 1, 2015; revised April 1, 2020

Revision History

08/23added

Added criteria III.E.1–III.E.4 for extracranial oligometastatic disease (one to three metastatic lesions involving the lungs, liver or bone; specified primary tumors: 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).

10/24coding_update