CurrentEmblemHealthPolicy N/A

Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiotherapy (SBRT) and Proton Beam Therapy (PBT)

Defines medical necessity criteria, covered indications, limitations/exclusions, applicable procedure (CPT/HCPCS) and ICD-10 diagnosis codes for SRS/SBRT and proton beam therapy for Commercial and Medicaid members (partial document - Part 1).

Policy Summary

PayerEmblemHealth

PolicyStereotactic Radiosurgery (SRS)/Stereotactic Body Radiotherapy (SBRT) and Proton Beam Therapy (PBT)

Policy CodePolicy N/A

Change TypeRevisions and additions to covered indications and case-by-case criteria (PBT/SRS/SBRT)

Effective Date

Next Review Date

Key ActionTreating physician or primary care provider must submit clinical evidence that the patient meets the criteria for the treatment; without documentation EmblemHealth will not be able to properly review the request for prior authorization.

SourceLink

POLICY UPDATE CHANGES

10/10/2025 - Reduced age threshold for case-by-case review from 21 to 19 years and younger for members with benign or malignant tumors or hematologic malignancies when PBT is intended for curative treatment.

5/17/2024 - Expanded covered indications for proton beam therapy to include additional cancerous/noncancerous tumor types, modified case-by-case list, and added clarifications for improved readability.

7/14/2023 - Added pediatric malignancies and maxillary sinus or paranasal/ethmoid sinus tumors as covered for PBT and removed Medicare notes, added links to NGS LCDs.

5/7/2021 - Amended NSCLC language for SBRT; stage II changed to stage IIA and amended PBT case-by-case language for NSCLC stage groupings.

4/12/2019 - Added PBT coverage for malignancies requiring craniospinal irradiation and for unresectable HCC/intrahepatic cholangiocarcinoma; expanded PBT case-by-case indications.

10/12/2018 - Added covered indications for malignant primary tumors of the adrenal gland, kidney, liver and pancreas.

1/12/2017 - Modified brain metastasis criteria for SRS to include Karnofsky scoring, lesion size/characteristics and utilization parameters; neurologic diseases added as covered indications.

12/1/2016 - Prostate cancer criteria modified for SBRT to include high-risk members.

9/9/2016 - For proton beam therapy, separated criteria per line of business and added Stage IIA seminoma indication for Commercial and Medicaid members; added Group 1 and Group 2 indications for Medicare members.

3/11/2016 - Added case-by-case language for boost treatment of larger cranial or spinal lesions within malignant primary tumors/lesions section.

21+PBT covered indications listed

10Nonmalignant SRS indications listed

5SRS metastatic brain scenario variants

~150+ICD-10 codes enumerated (partial)

~60ICD-10 codes (approx)

Coverage Summary

This policy (Part 1) defines medical necessity criteria, covered indications, limitations/exclusions, and applicable procedure and diagnosis codes for Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiotherapy (SBRT) and Proton Beam Therapy (PBT) for Commercial and Medicaid members. The coverage stance is mixed (specified indications covered; others not medically necessary). Modalities referenced include LINAC, Gamma Knife, and proton therapies. Pediatric case-by-case review threshold for curative-intent PBT is 19 years and younger (revised from 21). Status: CURRENT; Last review date: July 11, 2025; Effective/next review dates as listed in the document header.

Key thresholds and quick facts

Lesion size for brain metastasisNo lesion > 5 cm

Karnofsky Performance Status (KPS)> 70

Life expectancy for SRS after prior WBRT> 6 months

Prostate bone scan recencyNegative within the last 6 months (where applicable)

SBRT pancreatic chemotherapy requirementMinimum of 2 cycles of chemotherapy and restaging with no progression before pre-op/definitive treatment

PBT covered indications count21+

Nonmalignant SRS indications count10

ICD-10 diagnosis codes enumerated~150+ (partial list in document)

Medical Necessity — SRS / SBRT (Commercial & Medicaid)

SRS/SBRT - Commercial and Medicaid members (Medically Necessary)

Single or multiple-session (fractionated) SRS/SBRT utilizing any FDA-approved Gamma Knife or LINAC technology is considered medically necessary for any of the following:

A. Nonmalignant cranial/spinal/CNS tumors/lesions

A. Nonmalignant cranial/spinal/CNS tumors/lesions - list
- Arteriovenous (AV)/cavernous malformations
- Acoustic neuroma
- Craniopharyngioma
- Glomus tumor

Limitations & Exclusions — SRS / SBRT (Not Medically Necessary)

SRS/SBRT - Limitations/Exclusions (Not Medically Necessary)

Stereotactic radiosurgery is regarded as investigational and not medically necessary for the following indications:

Limitations/Exclusions

Gliomas (case-by-case consideration for inoperable malignant gliomas that have received prior radiation treatment)
Chronic pain syndromes
Extracranial lesions/tumors (other than those depicted above)
SBRT for palliation is not considered medically necessary

Medical Necessity — Proton Beam Therapy (PBT) (Commercial & Medicaid)

Proton Beam Therapy (PBT) - Commercial and Medicaid members (Medically Necessary)

PBT is considered medically necessary for the curative treatment of any of the following:

PBT - Covered indications

Chondrosarcomas and chordomas of the skull base; localized and in postoperative setting
Primary CNS cancer (excluding IDH wild-type glioblastoma multiforme)
Nonmetastatic primary tumors requiring craniospinal irradiation (e.g., medulloblastoma)
Primary ocular tumors including uveal melanomas when preferential compared to brachytherapy

Limitations & Exclusions — Proton Beam Therapy

Proton Beam Therapy - Limitations/Exclusions

PBT is not considered medically necessary for indications other than those listed above due to insufficient evidence; case-by-case consideration given for special situations.

PBT Limitations/Exclusions: Any indication not specifically listed as medically necessary above

Case-by-case consideration will be given for special situations

Applicable Procedure and Diagnosis Codes

Applicable Procedure Codes (SRS/SBRT and PBT)mixedCovered

Refer to policy Download (PDF) for full CPT/HCPCS procedure code list for SRS/SBRT and Proton Beam Therapy

Applicable ICD-10 Diagnosis Codes (Proton Beam)ICD-10Covered

C03.1	Malignant neoplasm of upper gum
C03.9	Malignant neoplasm of gum, unspecified
C04.0	Malignant neoplasm of floor of mouth
C04.1	Malignant neoplasm of dorsal surface of tongue
C04.8	Malignant neoplasm of overlapping sites of floor of mouth
C04.9	Malignant neoplasm of floor of mouth, unspecified
C05.0	Malignant neoplasm of palate, hard
C05.1	Malignant neoplasm of palate, soft
C05.2	Malignant neoplasm of uvula
C05.8	Malignant neoplasm of overlapping sites of palate

1–10 of 17

1/2

Applicable ICD-10 Diagnosis Codes (Gamma Knife / LINAC specific entries)ICD-10Covered

C07	Malignant neoplasm of parotid gland
C08.0	Malignant neoplasm of submandibular gland
C08.1	Malignant neoplasm of sublingual gland
C08.9	Malignant neoplasm of major salivary gland, unspecified
C09.0	Malignant neoplasm of tonsillar fossa
C09.1	Malignant neoplasm of tonsillar pillar
C09.8	Malignant neoplasm of overlapping sites of tonsil
C09.9	Malignant neoplasm of tonsil, unspecified
C10.0	Malignant neoplasm of vallecula
C10.1	Malignant neoplasm of anterior surface of epiglottis

1–10 of 18

1/2

Applicable ICD-10 Diagnosis Codes - Malignant neoplasms and secondary malignanciesICD-10

C40.00	Malignant neoplasm of unspecified shoulder
C41.1	Malignant neoplasm of long bones of upper limb, scapula and associated joints
C41.2	Malignant neoplasm of short bones of upper limb and associated joints
C41.3	Malignant neoplasm of long bones of lower limb and associated joints
C41.4	Malignant neoplasm of short bones of lower limb, including pelvis
C45.1	Malignant mesothelioma of pleura
C45.7	Malignant mesothelioma of peritoneum
C47.0	Malignant neoplasm of peripheral nerves and autonomic nervous system of head, face and neck
C48.0	Malignant neoplasm of retroperitoneum and peritoneum
C48.8	Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum

1–10 of 11

1/2

Applicable ICD-10 Diagnosis Codes - Carcinoma in situ, benign neoplasms, uncertain/unspecified behaviorICD-10

C69.00	Malignant neoplasm of conjunctiva, unspecified
C69.01	Malignant neoplasm of cornea
C69.02	Malignant neoplasm of lacrimal gland
C69.10	Malignant neoplasm of choroid, unspecified
C69.11	Malignant neoplasm of ciliary body
C69.12	Malignant neoplasm of retina
C69.20	Malignant neoplasm of optic nerve and visual pathways, unspecified
C69.21	Malignant neoplasm of optic nerve
C69.22	Malignant neoplasm of visual pathway
C69.30	Malignant neoplasm of orbit, unspecified

1–10 of 24

1/3

Applicable ICD-10 Diagnosis Codes - Neurologic & Vascular indications, historyICD-10

Include neurologic/vascular codes relevant to AV malformations, cavernous malformations, acoustic neuroma, hemangioblastoma, meningioma, schwannoma, and other CNS indications as appropriate per clinical documentation

Provider Actions & Authorization Requirements

Prior Authorization

Documentation requirement for prior authorization

The treating physician or primary care provider must submit clinical evidence that the patient meets the criteria for the requested SRS/SBRT or PBT treatment. EmblemHealth will not be able to properly review a prior authorization request without this documentation.

Documentation Required

Neurologic disease authorization

For neurologic disease indications (epilepsy, Parkinson's disease, essential tremor, trigeminal neuralgia and related refractory neurologic/vascular conditions), substantiating documentation that all standard medical and invasive neurosurgical treatments have proven ineffective must accompany the request. Discussion with a Medical Director may be required prior to authorization.

Background

SRS is a highly precise, non-surgical radiation therapy originally for intracranial lesions; when applied extracranially it is termed SBRT. Technologies and modalities discussed include Gamma Knife (intracranial), LINAC (intracranial or extracranial, including CyberKnife robotic LINAC variants), and Proton Beam Therapy (PBT). PBT uses accelerated protons delivered to the tumor and deposits most energy at the target (the Bragg peak) producing no exit dose beyond the tumor boundary. This dose-sparing property may allow better sparing of normal tissue and enable larger tumor doses when photon-based techniques cannot adequately spare surrounding structures.

Definitions:

- SRS: precise radiation delivered in single or few high-dose fractions (intracranial).

- SBRT: stereotactic body radiotherapy; SRS when applied extracranially.

- Fractionated stereotactic radiotherapy: multiple SRS treatments administered (typically up to 25).

- PBT (Proton Beam Therapy): uses protons which deposit most energy at the tumor site (Bragg peak) with no exit dose.

Referenced guideline sources and clinical context include the ACR‑ASTRO SBRT (2024) and ACR‑ASTRO Brain SRS (2023) practice guidelines, ASTRO model policies for PBT and SBRT, NCCN guidelines (CNS, esophageal, NSCLC, prostate, testicular), and relevant CMS Local Coverage Determinations (LCDs) for SRS/SBRT and PBT.

Medicare Determinations / LCDs

name	number	effective
Stereotactic Radiation Therapy: SRS and SBRT (LCD referenced 35076)	LCD referenced (35076) - link provided in document
Proton Beam Therapy (NGS LCD referenced)	NGS LCD referenced
Proton Beam Therapy (35075)	35075	2019-11
SRS/SBRT (Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy)	35076	2020-04

Revision History

3/11/2016revised

Added case-by-case language for boost treatment of larger cranial or spinal lesions within malignant primary tumors/lesions section.

9/9/2016revised

For proton beam therapy, separated criteria per line of business and added Stage IIA seminoma indication for Commercial and Medicaid members; added Group 1 and Group 2 indications for Medicare members.

12/1/2016revised

Prostate cancer criteria modified for SBRT to include high-risk members.

Policy Summary

PayerEmblemHealth

PolicyStereotactic Radiosurgery (SRS)/Stereotactic Body Radiotherapy (SBRT) and Proton Beam Therapy (PBT)

Policy CodePolicy N/A

Change TypeRevisions and additions to covered indications and case-by-case criteria (PBT/SRS/SBRT)

Effective Date

Next Review Date

SourceLink

On This Page

Spinal tumors - inoperable primary with compression or intractable pain

B. Malignant primary tumors/lesions

1. Prostate cancer
- Low-, intermediate-, and high-risk prostate cancer
- Negative bone scan within the last 6 months, where applicable
2. CNS: Initial or recurrence treatment (see Limitations/Exclusions for gliomas). Note: Boost treatment may be considered on a case-by-case basis for larger cranial or spinal lesions that have been treated initially with external beam radiation therapy or surgery.
3.: Uveal melanoma
4. Non-small cell lung cancer (NSCLC): Medically inoperable Stage I or node-negative Stage IIA
5.: Malignant primary tumors of the adrenal gland, kidney, liver and pancreas
Note regarding pancreatic cancer (SBRT up to 5 fractions): Stereotactic body radiation therapy (using up to 5 radiation treatment fractions) will be considered on a case-by-case basis consistent with eviCore for: pre-operative (after minimum 2 cycles of chemotherapy and restaging with no progression), definitive treatment for medically inoperable or locally advanced cases (after minimum 2 cycles of chemotherapy and restaging with no progression and disease volume can be entirely encompassed in the radiation treatment volume), and postoperative (adjuvant) cases with residual gross disease or positive microscopic margins that can be entirely encompassed in the radiation treatment volume.

C. Malignant metastatic tumors/lesions

1. Brain - Initial treatment
- Lesion no > 5 cmno > 5 cm
- Karnofsky Performance Status (KPS) > 70> 70
- Primary histology is not germ cell, small cell, or lymphoma
- Systemic disease is under control or good options for systemic treatment are available
- All lesions can be treated in a single treatment plan in a single fraction (for SRS) or up to 5 fractions (for fractionated SRS)max 5 fractions
  All lesions present on imaging must be targeted as a single episode of care; if cannot be accomplished in max 5 fractions, each fraction must be billed as 3D conformational or IMRT as appropriate
2. Brain - Retreatment in member with prior SRS
- 1-5 new lesions (no > 5 cm) present with evidence of controlled systemic disease1-5 lesions; no > 5 cm
- KPS score > 70> 70
- Primary histology is not germ cell, small cell, or lymphoma
- Member has not been treated with > 2 episodes of radiosurgery in past 9 months<= 2 episodes in past 9 months
- All lesions can be treated in a single treatment plan with a single fraction (for SRS) or up to 5 fractions (for fractionated SRS)
3. Brain - After prior whole-brain radiation therapy (WBRT): Member's KPS is > 70; Systemic disease is under control; Life expectancy is > 6 monthsKPS > 70; life expectancy > 6 months
4.: Member with NSCLC (curative treatment of primary tumor) presenting with 1-3 synchronous metastases1-3 metastases
5.: Spinal tumors - recurrent metastatic for members who have undergone prior surgery and conventional radiation therapy
6.: Member with colorectal cancer (curative treatment of primary tumor) presenting with 1-3 metastases in the lung or liver in synchronous setting and for whom surgical resection is not possible1-3 metastases
7.
- Histology is NSCLC, colon, breast, sarcoma, renal cell or melanoma
- Disease free interval of > 1 year from the initial diagnosis> 1 year
- Primary tumor received curative therapy and is controlled
- No prior evidence of metastatic disease (cranial or extracranial)

D. Tumors arising in areas overlapping previously irradiated regions: Tumors of any type arising in areas of overlap with previously irradiated regions where there is likely to be obvious clinical benefit

E. Neurologic diseases refractory to standard treatments

Epilepsy
Parkinson's disease
Essential tremor
Familial tremor classifications with major systemic disease
Trigeminal neuralgia

Nasopharynx, nasal cavity, paranasal sinuses or other accessory sinuses cancer

Hepatocellular cancer (HCC) or intrahepatic cholangiocarcinoma

Malignancies requiring Craniospinal Irradiation (CSI)

Individuals with cancer syndromes such as NF-1, Li-Fraumeni, Ataxia Telangiectasia (with deleterious ATM mutations), Hereditary Retinoblastoma, Lynch syndrome, or Hereditary Breast or Ovarian Cancer (with BRCA1/2 mutations)

Primary malignant or benign bone tumors

Unresected T3, T4, or node positive head and neck cancers

Thymomas and Thymic Carcinoma

Mediastinal lymphomas

Primary malignant pleural mesothelioma

Retroperitoneal Sarcoma

Individuals with a single kidney or transplanted pelvic kidney with treatment of an adjacent target volume

Liver metastases being treated with curative intent (i.e., oligometastases)

Leptomeningeal disease

Pediatric (age 19 years and younger) - case-by-case review for curative intent

Breast Cancer
Extrahepatic cholangiocarcinoma
Hodgkin's Lymphoma
Non-Hodgkin's Lymphoma
Lung Cancer
Pancreatic cancer
Prostate cancer
Cutaneous tumors with cranial nerve invasion to the base of skull, cavernous sinus and/or brainstem
Head and neck cancers requiring ipsilateral radiation treatment (e.g., oral cavity, salivary gland)
Mucosal melanoma
Adrenal cancers
Colon, anal or rectal cancers
Bladder cancer
Cervical, endometrial or ovarian cancers
Skin cancer
Palliative treatment

Billing Rule

Episode-of-care and fraction billing

All lesions identified on imaging must be targeted as a single episode of care. SRS/SBRT definition permits a single fraction (SRS) or up to 5 fractions (fractionated SRS/SBRT) per course. If all lesions cannot be treated within a maximum of 5 fractions, the service does not meet the SRS definition and each fraction must be billed as 3D conformational radiation therapy or IMRT based on the planning approach.

Treat all lesions on imaging in one treatment plan when using SRS/SBRT (single fraction or up to 5 fractions).
If treatment cannot be completed within ≤5 fractions, bill each fraction as 3D conformational RT or IMRT depending on planning.

Prior Authorization

Pediatric case-by-case review age threshold

Pediatric cases for certain indications will be reviewed on a case-by-case basis when PBT is intended for curative treatment for children 19 years and younger (revision reduced the threshold from 21 to 19 years).

1/12/2017revised

Brain metastasis criteria modified for SRS to include Karnofsky scoring, lesion size/characteristics and utilization parameters; neurologic diseases added as covered indications.

10/12/2018added

Added covered indications for malignant primary tumors of the adrenal gland, kidney, liver and pancreas.

4/12/2019revised

Added PBT coverage for malignancies requiring craniospinal irradiation and for unresectable HCC/intrahepatic cholangiocarcinoma; expanded PBT case-by-case indications.

5/7/2021revised

Amended NSCLC language for SBRT; stage II changed to stage IIA and amended PBT case-by-case language for NSCLC stage groupings.

7/14/2023revised

Added pediatric malignancies and maxillary sinus or paranasal/ethmoid sinus tumors as covered for PBT and removed Medicare notes, added links to NGS LCDs.

5/17/2024revised

Expanded covered indications for proton beam therapy to include additional cancerous/noncancerous tumor types, modified case-by-case list, and added clarifications for improved readability.

10/10/2025revisedLatest

Reduced age threshold for case-by-case review from 21 to 19 years and younger for members with benign or malignant tumors or hematologic malignancies when PBT is intended for curative treatment.

All lesions present on imaging must be targeted as a single episode of care; if cannot be accomplished in max 5 fractions, bill as 3D conformational or IMRT depending on planning