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    v1.0.31
    OpenPayerPolicy UpdatesRegence BlueCross BlueShieldRegence SRS/SBRT Coverage Criteria | OpenPayer
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    CurrentRegence BlueCross BlueShieldPolicy 213

    Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites

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    Coverage review for SRS and SBRT/SABR used to treat neoplastic and non-neoplastic conditions at intracranial, skull base, and orbital sites, with clinical documentation required to support medical necessity.

    Policy Summary
    PayerRegence BlueCross BlueShield
    PolicyStereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites
    Policy CodePolicy 213
    Change TypeNo material change
    Effective DateNovember 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateJuly 1, 2027
    Key ActionSubmit clinical documentation supporting the policy criteria for medical necessity review.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1 fractionCommon SRS treatment schedule
    2–5 fractionsCommon SBRT/SABR treatment schedule
    16Named medically necessary condition categories
    5Maximum fraction or session count

    Medical Necessity and Coverage Criteria

    Medically Necessary

    SRS and SBRT/SABR may be considered medically necessary for initial treatment or treatment of recurrence for any covered indication, when the applicable policy criteria are met.

    Covered indication

    • ONE of

      • Primary CNS neoplasm: Primary neoplasm of the central nervous system.
      • CNS metastasis: Metastasis to the central nervous system with an adequate performance score.
      • Arteriovenous malformation.
      • Skull-base chordoma or chondrosarcoma: Chordoma or chondrosarcoma of the skull base.
      • Cavernous malformation.
      • Craniopharyngioma.
      • Drug-resistant epilepsy, when applicable criteria are met.
      • Head and neck cancer when reirradiation is delivered.
      • Hemangioblastoma.
      • Hemangiopericytoma.
      • Glomus tumor: Glomus jugulare or glomus tympanicum tumor.
      • Meningioma.
      • Pituitary adenoma.
      • Schwannoma.
      • Trigeminal neuralgia refractory to medical management.
      • Uveal melanoma.

    Medically Necessary Indications

    SRS or SBRT may be medically necessary for initial treatment or treatment of recurrence when policy criteria are met.

    ONE of the following indications

    • Primary neoplasms of the central nervous system.
    • Metastasis to the central nervous system with an adequate performance score.
    • Arteriovenous malformations.
    • Chordomas or chondrosarcomas of the skull base.
    • Cavernous malformations.
    • Craniopharyngiomas.

    Investigational or Criteria-Not-Met Use

    SRS and SBRT are considered investigational when the indication is outside the covered criteria or applicable policy criteria are not met.

    Investigational use

    • At least one applies

      • The tumor or indication is not one of the medically necessary indications listed in the policy.
      • Applicable policy criteria are not met.

    All other tumors or indications are considered investigational when the applicable policy criteria are not met. The policy states that there is insufficient research to demonstrate that SRS or SBRT for intracranial, skull base, or orbital sites improves health outcomes in these circumstances.

    Coding and Billing

    Treatment Planning ServicesCPT
    77399Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services
    77301Intensity modulated radiotherapy plan, including dose volume histograms for target and critical structure partial tolerance specification
    77338Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan
    Treatment DeliveryCPT
    32701Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment
    77371Radiation therapy delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based
    77372Radiation therapy delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based
    77373Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fraction
    77435Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
    Clinical Treatment Management and Additional Stereotactic Servicesmixed
    61796Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion
    61798Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion
    61799Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex
    61800Application of stereotactic headframe for stereotactic radiosurgery
    63620Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion
    63621Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion
    77432Stereotactic radiation treatment management of cerebral lesion(s), complete course of treatment consisting of one session
    G0339Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment
    G0340Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment
    G0563Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5
    Maximum fraction or session count
    Applicable servicesSpecified fractionated SBRT/SRS delivery and treatment-management services
    Maximum course lengthEntire course not to exceed 5 fractions or sessions
    Included delivery examplesCPT 77373, CPT 77435, HCPCS G0340, and HCPCS G0563

    Documentation and Submission Requirements

    Documentation Required

    Submit Documentation for Medical Necessity Review

    Submit supporting clinical documentation for medical necessity review so Regence can determine whether the policy criteria are met.

    Documentation Required

    Required Clinical Records

    Submit the applicable clinical records required to evaluate the indication and treatment.

    • History and physical and chart notes, including documentation required by the applicable policy criteria
    • Treatment details and, when applicable, the sites, size, and number of lesions
    • When applicable, the documented ECOG score or Karnofsky performance score

    Treatment Overview

    SRS and SBRT/SABR use highly focused radiation beams and three-dimensional imaging to localize and treat a target while limiting exposure to surrounding normal tissues. SRS generally refers to intracranial treatment and is commonly delivered in 1 fraction, whereas SBRT/SABR commonly uses 2–5 fractions. These techniques may be used for lesions that are difficult to access surgically, close to vital structures, or subject to movement.

    Definitions and Evidence Categories

    Neoplasm
    DefinitionAn abnormal mass of tissue resulting when cells divide more than they should or do not die when they should
    Benign characteristicMay be benign, meaning not cancer
    Malignant characteristicMay be malignant, meaning cancer
    Arteriovenous malformation
    DefinitionA category of vascular malformation
    Included conditionIncludes dural arteriovenous fistula
    Alternate termDural arteriovenous malformation
    Policy Summary
    PayerRegence BlueCross BlueShield
    PolicyStereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites
    Policy CodePolicy 213
    Change TypeNo material change
    Effective DateNovember 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateJuly 1, 2027
    Key ActionSubmit clinical documentation supporting the policy criteria for medical necessity review.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaCoding and BillingDocumentation and Submission RequirementsTreatment OverviewDefinitions and Evidence Categories
  1. Drug-resistant epilepsy when applicable criteria are met.
  2. Head and neck cancer when reirradiation is delivered.
  3. Hemangioblastoma.
  4. Hemangiopericytoma.
  5. Glomus jugulare or glomus tympanicum tumors.
  6. Meningiomas.
  7. Pituitary adenomas.
  8. Schwannomas.
  9. Trigeminal neuralgia refractory to medical management.
  10. Uveal melanoma.
    11. Billing Rule

    Account for Image Fusion in Treatment Planning

    Account for image fusion used to provide enhanced delineation of target and normal critical structures within treatment planning. Report CPT 77399 when applicable; image fusion is considered part of treatment planning.

    • CPT 77399 — Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services
    Denial Risk

    Missing Required Clinical Documentation

    If required clinical documentation is not submitted, it could affect Regence’s ability to complete the review and may impact the decision outcome.

    Denial Risk

    Indication Outside Policy Criteria

    For tumors or indications outside the policy criteria, or when the criteria are not met, SRS or SBRT of intracranial, skull base, and orbital sites is considered investigational because sufficient research has not shown improved health outcomes.

    Schwannoma
    DefinitionTumors that occur along nerves
    Typical behaviorTypically benign, but may be malignant
    Vestibular schwannomaAlso known as an acoustic neuroma
    Performance status
    PurposeFunctional assessment used in oncology to help determine prognosis and management strategies
    Karnofsky systemKarnofsky Performance Status (KPS), scored from 10 to 100
    ECOG systemEastern Cooperative Oncology Group (ECOG) Performance Status, scored from 0 to 4
    Fractionated stereotactic radiotherapy
    DefinitionSRS or SBRT performed more than once on a specific site
    Common SRS scheduleSRS is commonly delivered in one fraction
    Common SBRT/SABR scheduleSBRT or SABR is commonly delivered in two to five fractions
    Stereotactic radiosurgery (SRS)
    TechniqueStereotactic radiation technique using multiple photon radiation beams
    TargetingBeams intersect at a stereotactically determined target
    Treatment effectPermits higher-dose delivery while sparing surrounding normal tissue
    Stereotactic body radiation therapy (SBRT)
    DefinitionStereotactic radiation delivered using radiation sources or high-energy photons
    Radiation sourcesMay use cobalt-60 gamma radiation, LINAC-generated photons, or particle beams
    Treatment sitesLINAC-based devices may be used for intracranial and extracranial lesions
    Image-guided radiosurgery or radiotherapy
    DefinitionRadiosurgery or radiotherapy delivered with real-time image guidance
    Example deviceCyberKnife
    Other examplesBrainLAB Novalis, TomoTherapy, and LINAC with computerized tomography (CT)
    Gamma Knife
    Device typeGamma radiation device for stereotactic radiosurgery
    Radiation sourceUses multiple cobalt-60 energy sources
    Common useGamma Knife is identified as the most commonly used gamma-ray device
    LINAC-based system
    System typeLinear accelerator system
    Radiation generationGenerates high-energy x-ray photons, generally using one energy source
    ExamplesCyberKnife, Novalis Tx, and TrueBeam STx
    Treatment sitesMay be used for intracranial and extracranial lesions
    WBRT
    AbbreviationWBRT means whole brain radiation therapy
    Use with metastasesUsed for treatment of brain metastases
    Combination optionsMay be used alone or in combination with SRS
    Cavernous malformation (CM)
    AbbreviationCM means cavernous malformation
    Anatomic descriptionAn intracranial vascular lesion
    Treatment contextEvaluated in studies of single-fraction SRS
    dAVF
    AbbreviationdAVF means dural arteriovenous fistula
    Condition typeA dural arteriovenous vascular lesion
    Treatment contextTreated with SRS in the summarized systematic review and meta-analysis
    NCCN Category 1
    Evidence levelHigh-level evidence
    NCCN consensusUniform NCCN consensus
    AppropriatenessThe intervention is considered appropriate
    NCCN Category 2A
    Evidence levelLower-level evidence
    NCCN consensusUniform NCCN consensus
    AppropriatenessThe intervention is considered appropriate
    NCCN Category 2B
    Evidence levelLower-level evidence
    NCCN consensusNCCN consensus that the intervention is appropriate
    Category distinctionUnlike Category 2A, the policy does not specify uniform consensus for Category 2B
    NCCN Category 3
    Evidence levelAny level of evidence
    NCCN consensusMajor NCCN disagreement that the intervention is appropriate
    Default recommendation noteRecommendations in the cited NCCN material are Category 2A unless otherwise noted
    ISRS Class I evidence
    Evidence typeHigh-quality randomized trial evidence
    Statistical supportA statistically significant difference or no statistically significant difference with narrow confidence intervals
    Review supportA homogeneous systematic review of Class I randomized controlled trials
    ISRS Level III recommendation
    Recommendation levelLevel III
    CertaintyClinical uncertainty
    BasisInconclusive or conflicting evidence or opinion
    Intracranial cavernous malformation (ICM)
    AbbreviationICM means intracranial cavernous malformation
    Condition addressedIntracranial cavernous malformation
    ISRS contextAddressed in ISRS recommendations for selected symptomatic or surgically inaccessible lesions