CurrentUnitedHealthcarePolicy CS180ID.B

Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Idaho Only)

This UnitedHealthcare medical policy applies only to the state of Idaho (including Idaho Medicaid Plus) and defines medically necessary indications, clinical criteria, documentation, definitions, and applicable procedure codes for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT)/SABR/FSRT.

Policy Summary

PayerUnitedHealthcare

PolicyStereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Idaho Only)

Policy CodePolicy CS180ID.B

Change TypeDocumentation requirement added

Effective DateApr 1, 2026

Next Review Date

Key ActionPatient medical records must contain relevant medical history, physical exam, and diagnostic tests/results that fully support medical necessity; documentation must be legible and available upon request.

POLICY UPDATE CHANGES

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

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

Archived previous policy version CS180ID.A.

MultipleCovered Indications Listed

10Max lesions (newly diagnosed brain mets)

3Max lesions (oligometastatic disease)

Max fractions for SBRT course

1Material policy change (documentation)

Coverage Summary

Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT/SABR) are highly focal, high-dose external beam radiation approaches used to treat intracranial and extracranial targets with the goal of maximizing tumor dose while minimizing exposure to adjacent normal tissues. SRS ordinarily refers to a single-session, high-dose cranial procedure whereas SBRT/SABR denotes extracranial stereotactic treatments typically delivered in ≤ 5 fractions. The rationale for these modalities is durable local control with a favorable safety profile for appropriately selected indications and dose-fractionation schemes. Professional society guidance (e.g., ASTRO, NCCN, ISRS, ACR) and systematic reviews/meta-analyses support use of SRS/SBRT for multiple tumor types and clinical scenarios when specified clinical criteria are met, with established dose and fractionation recommendations and device/coding descriptors to guide practice.

High-level scope and numeric thresholds

ScopeIdaho only medical policy defining medically necessary indications, clinical criteria, documentation, and applicable procedure codes for SRS and SBRT/SABR/FSRT

Payer/StateUnitedHealthcare — Idaho (including Idaho Medicaid Plus)

Effective dateApril 1, 2026

Coverage stanceCovered with criteria (coverage when specified clinical criteria are met)

Max lesions — newly diagnosed brain metastasisUp to 10 lesions (or cumulative tumor volume < 15 cc)

Max lesions — oligometastatic diseaseUp to 3 metastatic lesions (since diagnosis; prior treated lesions count toward 3)

Max fractions per SBRT courseEntire SBRT course not to exceed 5 fractions (oligometastatic SBRT must be completed in 5 fractions)

Evidence volume / qualityEvidence volume: high across tumor types; quality: variable with many retrospective studies

Medical-Necessity Criteria

General Coverage Rationale - Proven and Medically Necessary Indications

Stereotactic radiation therapy (SRS/SBRT) is considered proven and medically necessary for the following indications when specified clinical criteria are met:

Acoustic neuroma (vestibular schwannoma)

ALL of the following

Newly diagnosed brain metastasis
- Individual has good performance status (KPS ≥ 70% or ECOG 0-2)KPS >= 70% or ECOG 0-2
- Absence of leptomeningeal metastases

Provider Actions and Documentation Requirements

Documentation Required

Medical record support for medical necessity

Maintain comprehensive medical record documentation that supports the medical necessity of stereotactic radiation therapy (SRS/SBRT). Records should be legible, contemporaneous, and available on request.

Include relevant medical history and physical exam findings.
Include diagnostic imaging, radiology reports, and image-guided planning data.
Document prior treatments (surgery, previous radiation, systemic therapy) with dates and sites.
Document clinical rationale for SRS/SBRT and alternative treatments considered.
Provide signed radiation oncology treatment plan and consent forms.

Documentation Required

Restaging documentation for repeat brain SRS/SBRT

Applicable Procedure Codes

Applicable CPT/HCPCS codes listedmixed

32701	Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment.
61796	Stereotactic radiosurgery; 1 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.
63620	Stereotactic radiosurgery; 1 spinal lesion.
63621	Stereotactic radiosurgery; each additional spinal lesion.
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.

1–10 of 17

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Definitions and Key Thresholds

Key definitions used in the policy: Definitive Treatment — radiation given with curative intent; Oligometastatic Disease — limited metastatic stage (policy defines up to 3 metastatic lesions, excluding oligoprogression); SRS — stereotactic radiosurgery, high-dose, highly focal radiotherapy commonly for intracranial lesions (often single fraction); SBRT / SABR / FSRT — stereotactic body/s ablative radiotherapy or fractionated stereotactic radiotherapy, high-dose-per-fraction conformal EBRT to extracranial targets delivered in a small number of fractions (policy uses ≤ 5 fractions for SBRT courses); ARE — adverse radiation events; BED — biologically effective dose (used to compare regimens and inform thresholds associated with local control); performance status scales referenced are KPS / ECOG with policy thresholds of KPS ≥ 70% or ECOG 0–2.

Clinical thresholds and dose/fraction examples

KPS performance statusKPS ≥ 70%

ECOG performance statusECOG 0-2

Newly diagnosed brain metastases countUp to 10 lesions or cumulative tumor volume < 15 cc

Repeat brain metastases (past 12 months)

Evidence Summary

Evidence finding	Value / Numeric outcome
Acoustic neuroma tumor control
~90-96% local control reported across series/meta-analyses
Hearing preservation after SRS (VS)
59.4% (median follow-up 6.7 years) in meta-analysis
Yamamoto JLGK0901 SRS outcomes for 5-10 BMs
Median OS ~10.8-13.9 months depending on group; non-inferior to 2-4 BMs
Brain metastases dose recommendation
2,000-2,400 cGy single-fraction for intact BMs <2 cm; multifraction options 2,700 cGy/3 or 3,000 cGy/5
HCC SBRT local control (Jang 2020)
2-year LC 97%; 3-year LC 95%; severe toxicity at 1 year 3%
HCC SBRT vs RFA (Wang 2020)
SBRT non-inferior for OS; superior local control for tumors >2 cm
NSCLC SABR (TROG CHISEL)
Reduced local failure with SABR (HR 0.32); similar major toxicity
NSCLC pooled SABR vs surgery (STARS/ROSEL)
3-year OS higher in SABR group (95% vs 79%) in pooled small sample
Pancreatic SBRT vs CFRT (Tchelebi 2020)
2-year OS 26.9% SBRT vs 13.7% CFRT; lower acute grade 3/4 toxicity with SBRT
Pancreatic SBRT - Herman et al. (2015)
Median OS 13.9 months; 1-year freedom from local progression 78%; late grade ≥2 GI toxicity 11%
Prostate SBRT - Jackson et al. (2019)
5- and 7-year bRFS 95.3% and 93.7%; late grade ≥3 GU 2.0% and GI 1.1%
Prostate ultrahypofractionation - Widmark et al. (2019)
Non-inferior to conventional fractionation for failure-free survival at 5 years; similar late toxicity
Renal SABR - FASTRACK II (Siva et al. 2024)
12-month local control 100%; grade 3 adverse events 10%; median follow-up 43 months
Extracranial oligometastatic - SABR-COMET
Improved OS and PFS with SABR; 5-year OS 42.3% vs 17.7%; no new safety signals
Oligometastatic NSCLC - Gomez/Iyengar
Local consolidative therapy/SABR improved PFS and OS vs maintenance/observation in randomized trials
Glomus jugulare tumors - Ong et al. (2022)
Aggregate tumor control 95%; symptomatic improvement 47% (mean follow-up 47 months)
Glomus jugulare - Guss et al. (2011)
Tumor control 97%, clinical control 95% across 19 studies (n=335)
Cavernous sinus hemangiomas - Lee et al. (2017)
100% imaging-confirmed regression; >50% volume reduction by 6 months in all patients (n=31)
AVM - obliteration rates (Ding et al. 2017)
63% at 5 years and 78% at 10 years (SM Grade III cohort)
AVM - repeat SRS obliteration (Kano et al.)
35%, 68%, 77%, 80% obliteration at 3,4,5,10 years after repeat SRS
Meningioma - Santacroce et al. (2012)
5- and 10-year PFS 95.2% and 88.6%; overall control rate ~92.5%
Pituitary non-functioning adenomas - Kotecha et al. (2020)
5-year local control ~94%; 10-year estimate 83%; hypopituitarism common (up to 21% in meta-analysis)
Recurrent gliomas - CyberKnife (De Maria et al. 2021)
Median OS from CK treatment 8.6 months; median PFS 7.1 months; acute neurologic AEs 3.6%; radiation necrosis 4.3%
Uveal melanoma local control (Parker et al. 2020)
Pooled local control ~96% (840/898 individuals) across studies
Uveal melanoma dose effect (Yazici et al. 2017)
≥45 Gy in 3 fractions associated with better control of large tumors; enucleation-free survival and dose relationships reported
SBRT palliative spine pain response (Sahgal et al. 2021)
Complete pain response at 3 months: SBRT 35% vs cEBRT 14% (p=0.0002); SBRT regimen 24 Gy in 2 fractions

Revision History

2026-04-01addedLatest

Added material documentation requirement: the patient's medical record must contain documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures; documentation must be legible, maintained in the record, and made available upon request.

removed

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

archived

Policy Summary

PayerUnitedHealthcare

PolicyStereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for Idaho Only)

Policy CodePolicy CS180ID.B

Change TypeDocumentation requirement added

Effective DateApr 1, 2026

Next Review Date

On This Page

Individual does not have lymphoma, germ cell tumor, or small cell carcinoma

Has up to 10 lesions or cumulative tumor volume of < 15 cc≤10 lesions or cumulative volume < 15 cc

All lesions must be treated in a single treatment for SRS, or in 2 to 5 fractions for SBRT/FSRTSRS: single treatment; SBRT/FSRT: 2-5 fractions

Repeat stereotactic radiation therapy

Individual has good performance status (KPS ≥ 70% or ECOG 0-2)KPS >= 70% or ECOG 0-2
Absence of leptomeningeal metastases
Stable extracranial disease documented on restaging studies dated within the past two monthsrestaging within past 2 months
Life expectancy > 6 months> 6 months
Total number of brain metastases treated in the past 12 months is ≤ 13≤ 13 in past 12 months
All lesions must be treated in a single treatment for SRS, or in 2 to 5 fractions for SBRT/FSRTSRS: single treatment; SBRT/FSRT: 2-5 fractions

Re-treatment after previous whole brain radiation therapy

Medical Records Documentation Used for Reviews (Policy History 04/01/2026)

Added language requires documentation to support medical necessity:

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services

Documentation includes but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available upon request

For repeat brain SRS/SBRT, provide restaging documentation demonstrating stability or progression of systemic disease and intracranial disease burden to justify retreatment.

Restaging imaging (MRI brain with and without contrast) dated within 60 days prior to proposed retreatment.
Documentation of extracranial disease status and systemic therapy history.
Record of prior brain radiation treatments (dates, fields, dose and fractionation) and interval since prior treatment.
Clinical notes describing neurologic status and performance status (KPS or ECOG).

Documentation Required

Thoracic surgery evaluation for NSCLC

For NSCLC cases considered for SBRT, document a thoracic surgery evaluation and multidisciplinary discussion when resection is an option, or clearly state why the patient is medically inoperable or declines surgery.

Thoracic surgeon consult note with assessment of operative candidacy.
Multidisciplinary tumor board summary including radiation oncology, thoracic surgery, and medical oncology recommendations.
If surgery declined or deemed not feasible, document reasons (comorbidities, patient preference, anatomic considerations).

Documentation Required

Consider SRS/SBRT per guideline recommendations

Consider SRS/SBRT in accordance with guideline recommendations and the policy’s clinical criteria; document that the patient meets indication-specific criteria.

For brain metastases: performance status, absence of leptomeningeal disease, number/volume of lesions, life expectancy.
For oligometastatic disease: number and size of lesions, control of primary tumor (≥3 months), and life expectancy ≥6 months.
For NSCLC: stage I or IIA with negative mediastinal nodes, tumor ≤5 cm, and surgical ineligibility or refusal.

Documentation Required

Dose-fractionation selection

Provide the dose and fractionation selection rationale in the record, including target definition, prescription dose, and justification when deviating from standard fractionation.

Record of selected dose-fractionation regimen and biologic rationale (e.g., tumor histology, size, location, prior radiation).
Justify fractionation for larger lesions, proximity to critical structures, or staged approaches (e.g., AVM staged SRS).
Document any dose constraints applied to organs at risk and tradeoffs considered.

Documentation Required

Patient selection and multidisciplinary evaluation

Document patient selection and multidisciplinary evaluation to demonstrate appropriate candidate selection for SRS/SBRT.

Document performance status (KPS or ECOG) and estimated life expectancy.
Multidisciplinary tumor board or documented consultation notes (surgical, medical oncology, radiation oncology).
Assessment of comorbidities and ability to tolerate treatment positioning and immobilization.

Prior Authorization

Consider prior treatment history and performance status

Consider the patient’s prior treatment history and performance status when authorizing SRS/SBRT; authorization may require these elements to be explicitly documented.

Prior authorization reviewers should receive documentation of prior radiation (site, dose, fractionation) and systemic therapies.
Include performance status (KPS ≥70 or ECOG 0-2 where required by indication).
Provide life expectancy estimates when relevant to the indication (e.g., >6 months for repeat brain treatments).

Documentation Required

Monitoring and toxicity evaluation

Maintain documentation of monitoring plans and toxicity evaluation during and after SRS/SBRT.

Planned on-treatment assessments and supportive care measures.
Post-treatment follow-up schedule and imaging plan to assess response and late effects.
Documentation of acute and late toxicity assessments and management plans.

Documentation Required

Histologic diagnosis for pineal region tumors

For pineal region tumors, ensure histologic diagnosis is documented when it affects management decisions; if managed empirically, provide rationale.

Pathology report when biopsy or resection performed.
If no tissue diagnosis, document radiographic features and multidisciplinary rationale for non-biopsy management.

Documentation Required

Dose considerations for AVM staged SRS

When staging AVM SRS is used, document dose considerations and staged treatment rationale to limit normal tissue exposure.

Planned staged dosing schedule and intervals between stages.
Volumetric data and rationale for dose per stage based on AVM size and location.
Documentation of expected cumulative dose to surrounding brain and critical structures.

Documentation Required

Optic nerve dose constraint for orbital/cavernous hemangiomas

For orbital or cavernous sinus hemangiomas and other lesions near the optic apparatus, document that optic nerve and chiasm dose constraints were considered and respected.

Planned maximum point and volumetric dose to optic nerves and chiasm with justification if constraints exceeded.
Alternative fractionation used to meet optic pathway constraints.

Note

Device approvals informational only

Device approvals information: note that device clearances (e.g., LINAC, Gamma Knife, robotic platforms) are informational and do not alone determine medical necessity or coverage.

Document the treatment platform used (for operational purposes).
Device regulatory status is informational; clinical criteria and documentation govern coverage decisions.

Documentation Required

Dose and fractionation justification

Provide explicit dose and fractionation justification when billing or requesting authorization for regimens outside commonly accepted standards.

Clinical rationale tied to tumor histology, size, location, prior therapy, or organ-at-risk constraints.
Literature or guideline citations when using non-standard regimens.
Clear description of expected benefit and risk compared with standard options.

Billing Rule

Fraction limits for SBRT/SRS courses

Observe fraction limits and billing rules for SBRT/SRS courses; document treatment course length and fraction count on claims and in the medical record.

SBRT/SRS course typically not to exceed 5 fractions unless clinically justified.
Report appropriate CPT/HCPCS codes that reflect number of fractions and include image guidance codes when applicable (e.g., 77373, 77435, G0339/G0340).
Indicate when staged treatments or multiple courses are delivered to the same or different sites and provide justification.

Total treated in past 12 months ≤ 13

Oligometastatic lesion count & sizeUp to 3 lesions; each lesion ≤ 5 cm

SBRT fraction limits — definitive/cranialSRS: single treatment for cranial lesions; FSRT/SBRT: 2–5 fractions for cranial lesions

SBRT course fraction limit — oligometastaticCompleted in 5 fractions for entire course regardless of number of lesions

SBRT palliative spineUsing 2 fractions or less; example dose: 24 Gy in 2 fractions

Common dose-fraction examplesSingle-fraction cranial SRS: 2000–2400 cGy for intact BMs <2 cm; multifraction options: 2700 cGy/3 fx or 3000 cGy/5 fx; NCCN cranial SRS examples: 16–20 Gy×1, 24–27 Gy×3, 30 Gy×5; NSCLC RTOG 0236: 18 Gy×3 (54 Gy total); Pancreas common: 30 Gy/5; HCC example: 45–60 Gy in 3 fx

Archived previous policy version CS180ID.A.