Prior authorization may apply to listed SRS/SBRT procedure codes

The policy lists procedure codes commonly used for SRS/SBRT and notes these codes are provided for reference; prior authorization for these services may be required per the member’s plan. Use the listed codes when submitting authorization requests as applicable to the requested stereotactic procedure.

• Codes shown in policy (examples): 32701, 61796–61799, 61800, 63620–63621, 77301, 77371–77373, 77432, 77435, G0339, G0340, G0563
• Listing of a code in this policy does not guarantee coverage or payment; verify plan-specific prior authorization requirements

Authorize only with indication, performance status, prior RT history, and planned regimen

Prior authorization should document the clinical indication, performance status, prior radiotherapy to the site, and the planned dose and number of fractions consistent with guideline-recommended regimens.

• Confirm indication (e.g., symptomatic bone metastasis, limited brain metastases, oligometastatic disease)
• Document ECOG (or KPS) performance status and prior RT history
• Specify planned dose/fractionation consistent with ASTRO/NCCN guidance

Prior authorization must include ECOG, lesion number/size, prior cranial RT, and planned fractionation

For SRS requests for brain metastases, prior authorization should state ECOG performance status, number and size of metastases, any prior cranial RT (WBRT or prior SRS), and the planned fractionation/dose schedule.

• Document ECOG 0–2 (or KPS ≥70) per ASTRO recommendations
• Provide lesion count and maximum lesion diameter/cumulative volume (<15 cc when applicable)
• Note prior cranial radiation (WBRT or SRS) and the proposed single- or multi-fraction schedule (examples: 16–20 Gy x1; 24–27 Gy x3; 30 Gy x5)

Require documentation of dose constraints and image-guided RT for complex SBRT

Authorization reviewers should expect documentation that organ-at-risk dose constraints were evaluated and that image-guided radiation therapy was planned/used for complex SBRT cases (for example intrahepatic tumors).

• Confirm OAR/dose-constraint assessment (e.g., liver/GI constraints for hepatic SBRT)
• Indicate use of image-guided RT to improve accuracy and reduce toxicity when SBRT is planned

Capture clinical stage, treatment intent, and operability rationale in authorization

Prior authorization should capture disease stage and treatment intent and document that the patient is medically inoperable, at high surgical risk, or has declined surgery when SBRT is proposed as a definitive alternative.

• Record disease stage (e.g., stage I NSCLC) and multidisciplinary surgical evaluation
• Document rationale for nonoperative management (medically inoperable, high operative risk, or patient refusal)
• For pancreatic cases, state intended sequence with systemic therapy (neoadjuvant vs definitive)

For renal SBRT, document imaging/anatomic constraints and chosen dose regimen

When SBRT is requested for primary kidney tumors, prior authorization should document tumor size, anatomy relative to bowel/OARs, relevant imaging, and the selected dose regimen that aligns with guideline-recommended approaches.

• Provide tumor dimensions and proximity to bowel or other OARs (tumors abutting bowel may be unsuitable)
• Specify planned fractionation (examples per ISRS: 26 Gy x1 for ≤4–5 cm; 42–48 Gy in 3 fractions for >4–5 cm)
• Include imaging that supports safe delivery and OAR constraints

Confirm guideline-aligned patient selection (lesion count, controlled primary, performance status)

Prior authorization should confirm patients meet guideline-based selection for oligometastatic/metastasis-directed SBRT such as lesion count (commonly 1–5), controlled primary disease or response to systemic therapy, and acceptable performance status.

• Verify total metastatic lesion count (typically up to 5) and lesion sizes amenable to SBRT
• Document primary-tumor control or response to systemic therapy and life expectancy
• Confirm KPS ≥70 or ECOG 0–2 as applicable

Prior authorization for repeat or staged SRS must document prior SRS, residual volume, SM grade, and rationale

Authorization for repeat or staged SRS should document that the request is for residual or incompletely obliterated AVM or for a large AVM unsuitable for other approaches, and include prior treatment details and rationale for staged/repeat radiosurgery.

• Provide prior SRS parameters, residual nidus/target volume, and interval since prior treatment
• State Spetzler‑Martin grade and rationale for repeat or volume-staged approach

Document prior treatments and rationale for SRS/SBRT in authorization

Authorization should document prior interventions (e.g., surgery, embolization, prior radiotherapy) and provide the specific indication for SRS/SBRT consistent with evidence summaries (for example most NFPA SRS cases followed prior resection).

• List prior surgical resections or other local therapies and dates
• Provide justification for SRS/SBRT rather than alternative therapies

Verify trial-like eligibility (lesion limits, absence of cord compression, performance status)

Prior authorization should verify that the patient’s clinical status and lesion characteristics align with eligibility used in trials and guidelines (for example limited vertebral metastases, absence of cord compression, and acceptable performance status).

• Confirm absence of spinal instability or neurologic symptoms from cord compression when spinal SBRT is planned
• Ensure lesion number/location and prior RT history match trial/guideline eligibility or provide documented rationale

Recommend prior authorization include MDT review and specialized-center documentation

The policy recommends including multidisciplinary team selection and treatment at a specialized center in prior authorization documentation when applicable, to support patient selection and governance.

• Document multidisciplinary tumor board review and consensus
• Indicate specialized-center treatment when performed and note governance/consent processes

Verify member benefit plan terms and authorization tools before submitting requests

Before relying on this policy for authorization or coverage decisions, verify federal, state, and contractual benefit terms for the member’s plan; UnitedHealthcare may also use tools such as InterQual to determine prior authorization requirements.

• Check plan-specific benefit terms and any state/federal mandates that may affect coverage
• Be aware UnitedHealthcare may apply third-party criteria or tools in utilization review

Document rationale when preferring SBRT over conventional palliative RT

When choosing SBRT versus conventional palliative RT, document prognosis, prior RT, and the rationale for selecting SBRT; ASTRO conditionally recommends SBRT over conventional RT for selected patients (ECOG 0–2, no surgical intervention, absent neurologic symptoms).

• Record assessment of prognosis, prior RT doses, and expected survival
• Document why SBRT is preferred for this patient (e.g., faster/greater pain relief, prior trial evidence)

Document lesion burden and prior treatments when deciding WBRT vs SRS

For brain-directed therapy, document lesion burden and prior treatments to support selection of WBRT versus SRS; when disease is diffuse and not amenable to focal therapy, WBRT may be reconsidered per NCCN guidance.

• Provide lesion count, distribution, and prior cranial RT history
• If WBRT is chosen, justify based on diffuse intracranial disease not suitable for focal SRS

Document sequencing with other liver-directed therapies for hepatic SBRT

ASTRO guidance indicates EBRT/SBRT may be used as first-line for liver-confined HCC when curative and catheter-based options are not candidates; authorization should reflect sequencing relative to ablation/embolization when applicable.

• Document why ablation/embolization are not candidates (anatomic, prior failure, or medical contraindication)
• State planned sequencing (first-line EBRT/SBRT, consolidation, or salvage) in the authorization

Document multimodality sequencing when SBRT is planned for pancreatic cancer

For pancreatic cancer, authorization should document that SBRT is part of a multimodality plan (systemic chemotherapy ± surgery) for borderline resectable or selected locally advanced disease per ASTRO/NCCN conditional recommendations.

• Include details of neoadjuvant systemic therapy and restaging prior to SBRT when applicable
• State treatment intent (neoadjuvant, definitive, or salvage) and multidisciplinary discussion

For renal tumors, document operability assessment and rationale for SBRT

Guidance positions surgery as standard for operable renal tumors; authorization for SBRT in renal cell carcinoma should document nonoperability or patient refusal and multidisciplinary decision-making.

• Record surgical evaluation and rationale for nonoperative management
• Document tumor size and planned SBRT regimen aligned with ISRS/NCCN recommendations

No specific step-therapy algorithm — emphasize MDT evaluation and consideration of alternatives

No formal step-therapy sequences are specified in the policy; decisions emphasize multidisciplinary evaluation and consideration of alternative or prior systemic therapies before consolidative local SBRT.

• Ensure documentation of systemic therapy status and timing when consolidative SBRT is requested
• If alternatives (metastasectomy, supportive care) were considered, document rationale

Consider embolization after staged SRS for large AVMs; document sequencing and doses

When staged SRS is used for large AVMs, authors recommend considering embolization after staged radiosurgery to improve obliteration and reduce hemorrhage risk; document planned sequencing and rationale.

• Detail planned volume-staged SRS approach and any planned embolization adjunct
• Specify intended margin doses (minimum ~17 Gy suggested in staged series) and interval between stages

Document prior medical therapy and surgical evaluation for neurologic functional indications

For epilepsy (mesial temporal lobe) and similar neurologic indications, document prior adequate medical therapy trials and consideration of surgical alternatives, since randomized data favor surgery for seizure remission in eligible patients.

• Record medical therapy trials and responses, surgical candidacy evaluation, and patient preferences
• If SRS is chosen, document reasons for avoiding or deferring ATL (surgical resection)

Document regimen selection rationale considering prognosis, prior RT, and OAR risks

Select the RT regimen based on prognosis, prior RT, and normal tissue constraints; document these considerations and the chosen dose/fractionation consistent with ASTRO/NCCN guidance.

• Provide reasoning for regimen selection (e.g., BED considerations, prior dose to nearby OARs)
• Include anticipated toxicity risks and patient goals in pre-treatment assessment

For trigeminal neuralgia, document prior medical therapy trials before SRS

For trigeminal neuralgia, document prior adequate trials of medical therapy and that the patient remains refractory before requesting radiosurgery.

• List medications tried and duration/response
• Confirm multidisciplinary assessment and that standard arrangements for consent and governance are in place

Ensure complete medical record documentation is available to support medical necessity

The patient medical record must contain relevant history, physical exam, and results of diagnostic tests or procedures that fully support medical necessity; these documents must be available upon request for review.

• Include legible documentation of history, exam findings, and pertinent imaging/reports
• Make records available for utilization review or appeals

Document ECOG/KPS, tumor details, prior RT, life expectancy, intent, and planned dose/fractions

Required clinical documentation should include ECOG performance status (or KPS), tumor size and location, prior radiotherapy to the site, estimated life expectancy, treatment intent (palliative vs definitive), and planned dose-fractionation consistent with guideline recommendations.

• Record ECOG or KPS score (policy uses KPS ≥70 or ECOG 0–2)
• Provide tumor measurements, location, and prior RT history
• State life expectancy estimate and intended treatment intent

Include lesion size/number, prior cranial treatments, and planned dose-fractionation for brain SRS

For SRS for brain metastases, documentation should include lesion size, number, prior treatments (including prior WBRT or SRS), and the planned dose-fractionation regimen.

• List each lesion with size and location and cumulative tumor volume if relevant
• Document prior cranial treatments and the proposed single- or multifraction SRS schedule

Document baseline and follow-up toxicity assessments for selected SBRT contexts

Baseline and appropriate follow-up toxicity assessments should be documented for selected SBRT indications (for example EGD before and two months after liver SBRT in trials assessing gastroduodenal toxicity).

• When indicated, perform and document baseline and post-treatment evaluations (e.g., EGD for GI toxicity monitoring)
• Include plans for follow-up imaging and toxicity surveillance

Document operability assessment and MDT rationale when SBRT is used instead of surgery

Authorization and medical records should reflect multidisciplinary operability assessment (e.g., thoracic surgical evaluation) and the rationale when SBRT is chosen for patients at high operative risk or who decline surgery.

• Provide surgical evaluation notes or tumor board documentation showing operative risk assessment
• Document patient's decision-making or reasons for SBRT over surgery

Document post-treatment surveillance plans (imaging intervals); avoid routine post-SBRT biopsy

Post-treatment surveillance plans should be documented; routine post-SBRT biopsy is not recommended, but follow-up imaging (every six months for abdomen including kidneys/adrenals and chest imaging) is advised.

• State follow-up imaging schedule (e.g., cross-sectional abdominal imaging and chest imaging every six months)
• Note that routine post-treatment biopsy is not recommended unless imaging suggests progression

Include metastasis count/location, imaging of primary control, systemic therapy history, and MDT discussion

Supporting documentation for oligometastatic SBRT requests should include number and location of metastases, imaging confirming controlled primary disease or response to systemic therapy, prior systemic therapies and responses, and multidisciplinary tumor board discussion.

• Provide imaging confirming all metastatic sites and primary tumor status
• Include records of prior systemic therapy and response, and tumor board recommendations

For repeat/staged SRS, document prior treatments, residual volume, SM grade, and timing

For repeat or staged SRS requests, clinical records must document prior treatments (surgery, embolization, prior SRS), residual nidus/target volume, Spetzler‑Martin grade when applicable, and interval since prior SRS to justify retreatment strategy.

• Provide prior procedure details with dates and doses
• Document imaging demonstrating residual disease and quantitative target volumes

Document histologic diagnosis or rationale when biopsy is not feasible for pineal-region tumors

Obtain and document histologic diagnosis for pineal region tumors when feasible; if biopsy is not possible, document the rationale for presumptive diagnosis prior to SRS.

• Include pathology reports when available or a documented reason why biopsy was not feasible
• State expected histology-specific outcomes if known

Document pre-treatment assessment of prognosis, prior RT, OAR risks, QoL, and patient goals

Pre-treatment assessment should document prognosis, prior radiation doses, normal tissue risks, quality-of-life considerations, and patient values/goals before selecting an RT regimen for bone or other indications.

• Record estimated prognosis and expected benefit of SBRT versus alternatives
• Document prior RT doses and anticipated normal tissue constraints

Document MDT review, consent, governance, and device references when applicable

Document multidisciplinary team involvement, informed consent, clinical governance/audit arrangements, and when relevant, device product codes; perform procedures in specialized centers per NICE/other guidance.

• Include documentation of MDT review and informed consent
• Record device/product codes when device-specific information is pertinent (e.g., MUJ, IYE for FDA product lookup)

Verify plan benefit terms and applicable legal/contractual requirements before requesting authorization

Verify member plan benefit terms and state/federal contractual requirements prior to authorization; the policy is informational and plan-specific coverage governs.

• Check federal, state, or contractual requirements that may mandate or limit coverage
• Be aware UnitedHealthcare may use third-party tools (e.g., InterQual) in benefit administration

Denial risk: inadequate documentation may lead to service denial

Insufficient medical record documentation that does not fully support medical necessity may result in denial of the requested services.

• Ensure all requested clinical rationale, imaging, prior treatment records, and MDT notes are present in the record
• Provide clear, legible documentation that ties clinical facts to policy criteria

Denial risk: non–guideline-concordant regimen selection may prompt review

Use of SBRT outside recommended dose/fractionation ranges or without consideration of prognosis, prior RT dose, normal tissue risks, and patient goals may not align with guideline recommendations and could prompt utilization review or denial.

• Align planned doses/fractionation with ASTRO/NCCN guidance and cite rationale when deviating
• Document assessments of prior RT dose and normal tissue constraints

Denial risk: deviations from guideline lesion-count indications require justification

Requests for SRS that deviate from guideline indications (for example, treating more than recommended number of intact brain metastases) must include documented clinical justification or they may be subject to coverage review or denial.

• If requesting treatment beyond ASTRO lesion-count recommendations, provide explicit rationale and supporting evidence
• Document prior multidisciplinary discussion and patient-specific factors that support deviation

Denial risk: not meeting dose constraints or omitting image guidance may affect coverage

Failure to meet accepted dose constraints or to use image guidance when indicated (for example for unresectable intrahepatic cholangiocarcinoma) could lead to nonconcordance with guideline-preferred practice and affect coverage determination.

• Provide documentation that OAR dose constraints are achievable and will be met
• Indicate planned use of image-guided RT for accuracy and toxicity reduction

Denial risk: SBRT for standard-risk operable Stage I NSCLC is not supported outside trials

SBRT as an alternative to surgery for standard operative-risk Stage I NSCLC is not recommended outside clinical trials; claims for SBRT in operable, standard-risk patients may be questioned unless trial enrollment or strong rationale is provided.

• Include thoracic surgical evaluation and documentation if SBRT is proposed for potentially operable patients
• If treating an operable patient, document trial enrollment or clear contraindication to surgery

Denial risk: renal SABR eligibility exclusions (size, bowel proximity, prior RT, eGFR) must be addressed

Eligibility constraints observed in renal SABR trials (e.g., FASTRACK II) — tumors >10 cm, tumors abutting bowel, prior overlapping high-dose RT, prior systemic RCC therapy, or eGFR <30 mL/min/1.73 m² — may render patients inappropriate for trial-based SABR regimens and should be documented.

• If any of these exclusionary features are present, document reason why SBRT is still considered and provide supporting multidisciplinary justification
• Provide pre-treatment renal function and imaging addressing tumor–bowel proximity

Denial risk: inadequate documentation of staging, MDT review, or safe treatability for oligometastatic SBRT

Consolidative RT/SBRT for oligometastatic disease should be supported by guideline-specified patient selection (limited sites, controlled primary tumor, amenability to safe radiation); failure to document staging, MDT review, or amenability to safe delivery may risk denial.

• Document lesion count (typically ≤5), imaging confirming primary control or response, and MDT discussion
• Show that OAR constraints permit safe treatment of all intended targets

Denial risk: repeat SRS for AVMs requires documentation of prior attempts and risk counseling

Repeat SRS for AVMs carries measurable complication rates (radiation-induced changes, post-radiosurgery hemorrhage, neurologic deficits); inadequate documentation of prior obliteration attempts or failure and risk counseling may lead to denial.

• Provide documentation of prior obliteration attempts, imaging showing residual nidus, and informed-risk discussion with the patient
• Include Spetzler‑Martin grade and expected complication risks

Denial risk: prior RT, radiation-induced tumors, multiple lesions, or NF2 affect evidence applicability

Evidence series excluded patients with prior radiotherapy, radiation-induced tumors, multiple lesions, or NF2; presence of these features may affect the applicability of evidence and could influence coverage decisions if not justified in the record.

• If such exclusionary features are present, document rationale and any supporting evidence for treating outside the typical evidence base
• Provide MDT justification and alternative options considered

Denial risk: spinal instability, prior RT, or cord compression exclusions must be addressed

Trials commonly excluded patients with spinal instability, extensive contiguous vertebral involvement, prior RT at the site, or neurologic symptoms from cord compression; treatments outside these eligibility criteria should be justified in documentation.

• Document spinal stability assessment (e.g., Spinal Instability Neoplasia Score) and absence of neurologic compression when indicated
• If treating outside trial limits, provide multidisciplinary rationale and risk/benefit discussion

Denial risk: lack of specialized-center/MDT selection and governance may affect coverage

Procedures performed outside specialized centers or without multidisciplinary selection, governance, consent, and audit arrangements may not meet guideline expectations and could affect coverage.

• Document that care was planned or reviewed by an MDT and performed in an appropriately resourced center when recommended
• Include consent and clinical governance documentation

Denial risk: coverage contingent on meeting specified criteria (absence of diffuse BMs, lesion and fractionation limits)

Coverage is contingent on meeting the policy’s specific indications and criteria (for example absence of diffuse brain metastases, lesion counts and fractionation limits); requests not meeting revised criteria may be denied.

• Ensure requests meet the revised coverage criteria (e.g., no diffuse brain metastases; oligometastatic disease ≤5 lesions; SBRT spinal fractions ≤5)
• If criteria are not met, include detailed justification and supporting evidence