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).
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.
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