CurrentUnitedHealthcarePolicy CS180ID.B

Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS) (Idaho only)

Defines UnitedHealthcare medical policy (Idaho only, including Idaho Medicaid Plus) coverage criteria, indications, and applicable procedure codes for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT). Includes clinical definitions, documentation expectations, and a list of applicable CPT/HCPCS codes.

Policy Summary

PayerUnitedHealthcare

PolicyStereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS) (Idaho only)

Policy CodePolicy CS180ID.B

Change TypeAdded documentation requirement; removed reference link; archived prior version

Effective DateApr 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record contains relevant history, physical exam, and diagnostic test results that fully support medical necessity and make records available upon request.

POLICY UPDATE CHANGES

Added language requiring the patient's medical record to contain documentation that fully supports medical necessity for requested services.

Removed reference link to the guidelines titled 'Medical Records Documentation Used for Reviews'.

Archived previous policy version CS180ID.A.

MultipleCovered Indications Listed

Up to 10Lesions allowed (new brain mets / <15 cc)

Up to 3Oligometastatic lesions allowed

3-5Typical SBRT fractionation

100%12-mo local control (FASTRACK II renal)

Coverage Summary

This Idaho-only UnitedHealthcare medical policy (effective April 1, 2026) defines coverage criteria, indications, and applicable CPT/HCPCS codes for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT / SABR) for Idaho members, including Idaho Medicaid Plus. The policy lists covered indications, clinical definitions (SRS, SBRT/SABR, FSRT), documentation expectations, and references applicable procedure codes for SRS/SBRT services.

Medical necessity determinations and any required preauthorization for Idaho members are evaluated against the policy criteria and supported by medical record documentation as specified in the policy (history, exam, diagnostic tests) which must be legible and available on request.

Key thresholds & quick facts

KPS>= 70

ECOG performance status0-2

Newly diagnosed brain metastasesUp to 10 lesions OR cumulative tumor volume < 15 cc

Oligometastatic disease lesion countUp to 3 metastatic lesions (each <= 5 cm)

Max SBRT fractions (definitive/oligometastatic)Entire course ≤ 5 fractions

SBRT palliative spine fractionation2 fractions or less (per policy)

Life expectancy requirement> 6 months

Medical-Necessity Criteria

Definitions and Evidence Summary

SRS typically delivers a single high-precision, high-dose treatment to intracranial targets (with multifraction options for larger lesions), while SBRT (also called SABR) delivers high-dose external beam radiation to extracranial tumors in five fractions or less. Fractionation of SRS into 2–5 treatments (FSRT) may be used to improve safety for larger lesions by allowing normal tissue repair between high-dose fractions.

Term	Definition
Definitive Treatment
Radiation treatments for cancer with a curative intent (Landsteiner et al., 2023).
Oligometastatic Disease
Stage where cancer has spread beyond the primary site but is not widely metastatic; under this policy individuals with up to three metastatic lesions qualify; oligoprogression is not considered oligometastatic disease.
SRS
Stereotactic radiosurgery — highly focused radiation typically delivered in 1-5 high-dose fractions to intracranial lesions.
SBRT / SABR
Stereotactic body radiotherapy / stereotactic ablative radiotherapy — precise high-dose external beam radiation delivered to extracranial tumors in few fractions (usually ≤5).
FSRT
Fractionated stereotactic radiotherapy — stereotactic approach delivered over multiple fractions (commonly 2–5 for FSRT; policy notes FSRT refers to 2–5 fractions for larger lesions).
BED
Biologically effective dose — a radiobiological calculation used to compare different dose-fractionation regimens; policy notes BED thresholds (e.g., BED ≥100 Gy associated with improved NSCLC local control; BED10 >75 Gy associated with optimal local control).
OAR
Organ at risk — normal tissues near the target for which dose constraints must be observed.

Label	Key finding
Acoustic neuroma tumor control
Tumor control ~96.1% reported in Balossier et al. 2023 systematic review/meta-analysis (median follow-up 6.7 years).
Yamamoto (2014/2017) SRS for 5-10 BMs
SRS alone for up to 10 brain metastases non-inferior OS vs 2–4 BMs; similar complication rates (JLGK0901 observational study).
TROG 09.02 (CHISEL)
Phase 3 RCT: SABR improved freedom from local treatment failure vs standard RT in inoperable peripheral stage I NSCLC (HR 0.32, p=0.0077).
STARS + ROSEL pooled analysis
Pooled trials (Chang et al.): SABR showed higher 3-year OS (95% vs 79%) vs surgery in small dataset (HR 0.14, p=0.037).
RTOG 0236
SBRT 54 Gy in 3 fractions for medically inoperable early-stage lung cancer: 3-year OS 55.8%; primary tumor control ~97.6%.
Onishi / BED evidence
Higher BED associated with improved local control in NSCLC; BED ≥100 Gy linked to better outcomes (Onishi et al.).
Meta-analysis HCC (Rim 2019)
Pooled SBRT 1–3 year local control ~86–84%; grade ≥3 hepatic complications ~4.7%.
Pancreatic SBRT vs CFRT meta-analysis (Tchelebi 2020)
SBRT associated with higher 2-year OS (26.9% vs 13.7%) and lower acute grade 3/4 toxicity (5.6% vs 37.7%).
FASTRACK II renal SABR (Siva et al. 2024)
12-month local control 100%; grade 3 AEs 10%; regimens 26 Gy x1 or 42 Gy/3. Median tumor size 4.6 cm.
SABR-COMET long-term (Palma et al.)
Median OS 41 vs 28 months (SABR vs control); 5-year OS 42.3% vs 17.7%; improved PFS with SABR (extended follow-up).
Gomez et al. (oligometastatic NSCLC)
Local consolidative therapy prolonged PFS and OS vs maintenance/observation in stage IV NSCLC with ≤3 metastases after systemic therapy (Gomez et al.).
SBRT vs cEBRT for spinal metastases (Sahgal et al.)
Complete pain response at 3 months: 35% (SBRT) vs 14% (cEBRT); SBRT (24 Gy in 2 fractions) superior for pain relief.
SABR-COMET earlier report (Harrow 2022)
Extended follow-up: 8-year OS 27.2% (SABR) vs 13.6% (control); sustained PFS benefit.
NCCN/ASTRO/ISRS guideline endorsements
Multiple society guidelines support SRS/SBRT for indicated sites (brain mets, early-stage NSCLC, HCC, oligometastatic disease, renal and prostate SBRT per guideline statements).

Applicable Codes

Applicable CPT / HCPCS Codes (referenced for SBRT/SRS services)mixed

32701	Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment.
61796	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion.
61797	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure).
61798	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion.
61799	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure).
61800	Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure).
63620	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion.
63621	Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure).
77301	Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications.
77371	Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based.

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Provider Actions & Documentation Requirements

Documentation Required

Medical record documentation requirement for reviews

The patient's medical record must contain documentation that fully supports the medical necessity for the requested stereotactic radiation therapy service. Documentation must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures (e.g., imaging, histology, laboratory results). Medical records must be legible, maintained in the patient's medical record, and made available upon request. Change detail: updated to reaffirm that documentation is required to support medical necessity for reviews.

Medical records must support medical necessity for the requested service
Include relevant history, physical exam, imaging, and diagnostic test results
Make records available upon request

Prior Authorization

Policy applicability and preauthorization implication

Key Clinical Thresholds & Dose Examples

Thresholds and dose-fractionation (policy examples)

Karnofsky Performance Status (KPS)>= 70

ECOG performance status0-2

Newly diagnosed brain metastasesUp to 10 lesions OR cumulative tumor volume < 15 cc

Repeat brain metastasis total in past 12 months<= 13 lesions

Oligometastatic diseaseUp to 3 metastatic lesions; each <= 5 cm; SBRT completed in 5 fractions

Brain metastases lesion diameter for SRS< 2 cm (single-fraction option); multifraction options available

BED threshold associated with improved NSCLC control

Evidence Highlights

High-quality randomized and prospective trials and meta-analyses support SBRT/SABR and SRS in selected settings: SABR-COMET and related oligometastatic trials show OS and PFS benefits with SABR; RTOG 0236 demonstrates excellent local control and favorable 3-year OS for SBRT in inoperable early-stage NSCLC; pooled STARS/ROSEL data suggest comparable or improved OS with SABR versus surgery in select early-stage NSCLC; and a large prostate SBRT meta-analysis reports high biochemical control with low rates of late severe GU/GI toxicity. Overall, evidence shows strong local control and survival benefits in specific indications with generally low severe toxicity rates.

Prominent evidence metrics

12-month local control (FASTRACK II renal SABR)100%

5-year overall survival (SABR-COMET, SABR group)42.3%

Patients in prostate SBRT meta-analysis6,116 patients (pooled studies)

Prostate SBRT 5-year bRFS95.3%

Prostate SBRT late grade >=3 GU toxicity

Revision History

2026-04-01Policy changeLatest

Added language requiring the patient's medical record to contain documentation that fully supports medical necessity for requested services; documentation examples include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be legible and made available upon request.

2026-04-01Policy change

Removed reference link to the guidelines titled 'Medical Records Documentation Used for Reviews'.

2026-04-01Policy change

Policy Summary

PayerUnitedHealthcare

PolicyStereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS) (Idaho only)

Policy CodePolicy CS180ID.B

Change TypeAdded documentation requirement; removed reference link; archived prior version

Effective DateApr 1, 2026

Next Review Date

Key ActionEnsure the patient's medical record contains relevant history, physical exam, and diagnostic test results that fully support medical necessity and make records available upon request.

On This Page

This policy applies only to Idaho members, including Idaho Medicaid Plus plans. Prior authorization implications: services inconsistent with policy criteria may be denied or require additional documentation prior to coverage determination. Ensure preauthorization requests for SBRT/SRS for Idaho members reference this policy and include the supporting documentation described in the Medical Records Documentation callout.

Applies to Idaho members (including Idaho Medicaid Plus)
Prior authorization and documentation may be required for coverage determination

Documentation Required

Restaging requirement for repeat brain SRS

Restaging evidence must be provided for individuals undergoing repeat brain SRS/SBRT. Documentation should demonstrate stable extracranial disease and restaging studies dated within the past two months when required by the clinical criteria for retreatment.

Provide restaging studies dated within the past 2 months when repeat brain SRS is requested
Document stability of extracranial disease when applicable

Documentation Required

Dose-fractionation and indication documentation

Document the specific dose, fractionation schedule, and clinical indication for the proposed SBRT/SRS treatment in the medical record and in any preauthorization request. Include the prescribed total dose, dose per fraction, number of fractions, and rationale for the selected regimen relative to target size, location, and nearby critical structures.

Record total dose, dose per fraction, and number of fractions
Provide indication and rationale for chosen dose-fractionation

Documentation Required

Patient selection considerations

Document patient selection considerations that support the use of SBRT/SRS, including performance status (KPS or ECOG), life expectancy, prior treatments, and whether the individual is a surgical candidate or has refused surgery. For oligometastatic therapy, document lesion count, size, control of the primary tumor, and absence of contraindicating metastatic patterns (e.g., malignant pleural effusion).

Performance status (KPS ≥ 70% or ECOG 0–2)
Life expectancy ≥ 6 months when required by criteria
Document prior local therapies and surgical candidacy

Documentation Required

Multidisciplinary decision for renal SBRT

For renal SBRT, documentation must show a multidisciplinary decision supporting SBRT over surgery or other local therapies. Include documentation of tumor stage (Stage I), surgical risk or non‑optimal surgical candidacy, and imaging or biopsy results supporting the diagnosis when available.

Multidisciplinary tumor board or documented multidisciplinary decision required for renal SBRT
Document Stage I renal cancer and reasons surgery is not optimal

Documentation Required

Follow-up imaging after renal SBRT

After renal SBRT, provide follow-up imaging per institutional practice to assess treatment response and potential complications. Document baseline and follow-up imaging studies in the medical record to support continued care and any subsequent requests for services.

Document baseline imaging and post-treatment follow-up imaging
Include reports that assess response and complications

Documentation Required

Dose selection considerations for renal SBRT

When selecting dose for renal SBRT, document considerations such as tumor size, proximity to critical structures, and intent (definitive vs. palliative). Include rationale for hypofractionated regimens and any modifications made to protect adjacent organs at risk.

Document tumor size and relation to critical structures
Provide rationale for selected hypofractionated dose and any OAR constraints

Documentation Required

Consider histologic diagnosis for pineal tumors

For pineal gland tumors, document efforts to obtain a histologic diagnosis when feasible and note when treatment decisions are made based on imaging and clinical context if biopsy is not possible or is contraindicated.

Consider and document histologic diagnosis for pineal tumors when feasible
If biopsy not obtained, document rationale for treatment based on imaging/clinical factors

Documentation Required

Consider margin dose impact for AVM and large lesions

For intracranial AVMs and other large lesions, document how margin dose selection accounts for lesion size and potential increased risk. Note in records when margin dose is reduced or fractionation altered due to lesion size to mitigate risk to surrounding tissue.

Document margin dose decisions for AVM and large lesions
Explain dose/fractionation adjustments made because of lesion size

Documentation Required

Assessment prior to palliative spine RT

Prior to palliative spine radiation (including SBRT when indicated), assess and document whether spinal cord compression or cauda equina compression is present. Ensure imaging (e.g., MRI) and neurologic assessment are documented prior to treatment. SBRT for palliative spine metastases is limited to 2 fractions or less when indicated and when no cord compression exists.

Document imaging and neurologic assessment prior to palliative spine RT
Confirm absence of spinal cord or cauda equina compression when SBRT in ≤2 fractions is planned

Documentation Required

Dose and fractionation documentation and re-irradiation considerations

Document the prescribed dose and fractionation for all SBRT/SRS treatments, including re-irradiation considerations (previous radiation dates, cumulative dose to organs at risk, and interval since prior therapy). Provide justification for re-irradiation and planned dose constraints.

Record prescribed total dose and fractionation for each course
Document prior radiation history, cumulative dose to OARs, and interval since prior RT when re-irradiation is considered

Documentation Required

MDT involvement for trigeminal neuralgia and uveal melanoma

For procedures such as treatment of trigeminal neuralgia and uveal melanoma, document multidisciplinary involvement (e.g., neurosurgery, ophthalmology, radiation oncology) in treatment planning and decision-making.

Document MDT involvement for trigeminal neuralgia and uveal melanoma cases
Include specialist notes and consensus rationale

Note

Archived prior policy version

Archived prior policy version CS180ID.A has been retired and superseded by CS180ID.B effective 2026-04-01. Reference to prior language or criteria should be replaced by the current policy content.

CS180ID.A archived; superseded by CS180ID.B effective 2026-04-01

BED >= 100 Gy (clinically actionable)

Typical SBRT fractionation examplesNSCLC: 18 Gy x3 (54 Gy) or 60-66 Gy in 3 fractions; HCC: 45-60 Gy in 3 fractions; Pancreas: 30 Gy in 5 fractions

Renal SBRT dose selection<=4-5 cm: 26 Gy x1; >4-5 cm: 42-48 Gy in 3 fractions; alternative 40 Gy in 5 fractions if OAR constraints

SBRT spine / non-spine recommended doses (ASTRO)Spine: 2400 cGy in 2 fractions; Non-spine: 1200-1600 cGy in 1 fraction

The policy provides specific dose and fractionation examples (for brain, lung, liver, pancreas, prostate, kidney, spine, and other sites) and requires that the chosen dose-fractionation and clinical rationale be documented in the medical record. These examples must be used to support clinical justification and prior authorization decisions per the provider documentation requirements.

Complete tumor control rate (glomus jugulare tumors aggregated)~95%

Archived previous policy version CS180ID.A.