Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for New Jersey Only)
This policy governs coverage and medical necessity criteria for stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) for members in New Jersey, applying to individuals 19 years and older (with separate guidance for those under 19).
Policy Summary
PayerUnitedHealthcare
PolicyStereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for New Jersey Only)
Policy CodePolicy CS180NJ.F
Change TypeMaterial revisions and additions
Effective DateFeb 1, 2026
Next Review Date
Key ActionFollow payer prior authorization processes and document indication, prior radiation, performance status, and planned dose/fractionation when requesting SRS/SBRT.
Added notation to indicate this policy applies to individuals 19 years of age and older; stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) are covered without further review for individuals younger than 19 years of age.
Revised list of proven and medically necessary indications including additions (e.g., non-spine bone metastasis symptomatic up to five fractions; neurologic conditions refractory to treatment; expanded spinal lesion criteria).
Changed coverage criteria for newly diagnosed brain metastasis and repeat stereotactic therapy to require 'absence of diffuse brain metastases' and 'absence of diffuse leptomeningeal metastases', and removed small cell carcinoma from exclusion list.
Expanded extracranial oligometastatic disease allowed lesions from up to three to up to five metastatic lesions and clarified performance status language.
Added intrahepatic bile duct cancer (cholangiocarcinoma) for unresectable tumors to Definitive Treatment criteria.
Added notation that HCPCS code G0563 is not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program.
Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria but does not guarantee coverage.
Removed prior language limiting SBRT for palliative treatment of spinal bone metastases to 2 fractions or less; retained palliative spinal metastasis criteria with up to five fractions.
Notation added that HCPCS code G0563 is not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program.
Updated definition of 'Definitive Treatment' and 'Oligometastatic Disease (OMD)'.
≤5Max lesions for OMD
≤5 cmMax lesion size (OMD)
KPS ≥70 / ECOG 0-2Performance status
≤5 fxTypical SBRT course
G0563NJ Medicaid note
Coverage and Medical Necessity Criteria
Brain Metastasis (newly diagnosed)
Covered when ALL of the following are met for select indications (brain metastases examples):
Newly diagnosed brain metastasis criteria: Individual has a good performance status (KPS ≥ 70 or ECOG 0–2); absence of diffuse brain metastases; absence of diffuse leptomeningeal metastases; individual does not have a diagnosis of lymphoma or germ cell tumor; has up to 10 lesions or cumulative tumor volume < 15 cc; all lesions treated in a single treatment for SRS or in 2–5 fractions for SBRT (FSRT).KPS ≥70 or ECOG 0-2; ≤10 lesions or cumulative volume <15 cc; 1 or 2–5 fractions per modality
From Brain Metastasis (newly diagnosed) section
Brain Metastasis (repeat treatment)
Covered when ALL of the following are met for repeat stereotactic radiation therapy:
Repeat stereotactic radiation therapy criteria: Individual has a good performance status (KPS ≥ 70 or ECOG 0–2); absence of diffuse leptomeningeal metastases; extracranial disease is well-controlled or there are accessible and effective systemic treatment options available.KPS ≥70 or ECOG 0-2
From Brain Metastasis (repeat treatment) section
Covered Indications (selected)
Covered indications (selected list) — SRS/SBRT considered proven and medically necessary for the following diagnoses when criteria shown are met:
List of covered diagnoses: Acoustic neuroma (vestibular schwannoma); Bone metastasis (non-spine) when symptomatic and up to five fractions; Brain metastasis per criteria; Retreatment after prior whole brain radiation therapy; Chordoma and chondrosarcoma; Craniopharyngioma; Definitive treatment for HCC without regional or distant metastasis; Intrahepatic bile duct cancer (cholangiocarcinoma) for unresectable tumors; NSCLC stage I or IIA (N0) tumor ≤5 cm when medically inoperable or declines surgery; Pancreatic adenocarcinoma without distant metastasis; Prostate cancer without distant metastases; Renal cancer stage I for non-optimal surgical candidates; Early-stage SCLC (stage I or node-negative IIA) when medically inoperable/non-optimal surgical candidate; Extracranial oligometastatic disease meeting criteria; Glomus jugulare tumors; Hemangiomas of the brain; Intracranial AVMs; Meningioma; Neurologic conditions refractory to medical or invasive surgical treatment (epilepsy, Parkinson's disease, essential tremor); Pineal gland tumors; Pituitary adenoma; Recurrent gliomas; Spinal lesions meeting listed scenarios; Treatment of previously irradiated field; Trigeminal neuralgia refractory to medical therapy; Uveal melanoma.See individual indication criteria
Combined covered indications list
Extracranial Oligometastatic Disease
Covered when ALL of the following are met for Extracranial Oligometastatic Disease:
Oligometastatic disease criteria: Primary tumor type among colorectal, melanoma, non-small cell lung cancer, prostate, renal, or sarcoma; primary tumor controlled (≥ 3 months since definitive treatment) with no progression at the primary site; KPS ≥ 70 or ECOG 0–2; life expectancy ≥ 6 months; total of up to 5 metastatic lesions; each lesion ≤ 5 cm; no malignant pleural effusion, leptomeningeal or peritoneal carcinomatosis; all metastatic lesions treated concurrently in a single episode of care; SBRT course completed in ≤ 5 fractions for the entire course regardless of number of lesions treated.≤5 lesions; lesion size ≤5 cm; KPS ≥70 or ECOG 0-2; life expectancy ≥6 months
From Extracranial Oligometastatic Disease section
Spinal Lesions
Covered spinal lesion scenarios:
Spinal lesion coverage: Palliative treatment of symptomatic spinal bone metastasis using ≤5 fractions when there is no spinal cord or cauda equina compression and patient meets stability/surgical evaluation criteria; primary spinal lesions not amenable to surgical resection or 3D conformal techniques; treatment of previously irradiated field when appropriate reirradiation criteria and constraints can be met.≤5 fractions for palliative spinal bone metastasis; evaluate spine stability prior to RT
From Spinal Lesions section
SBRT for Nonspine Painful Bone Metastases
Covered when ALL of the following are met
Nonspine painful bone metastasis SBRT: Patient has painful non-spine bone metastasis with estimated life expectancy compatible with benefit (trial included >3 months); prior radiation to the site, untreated spinal cord compression, pathologic fracture at the site, and recent radioactive isotope therapy within 30 days are considerations that may exclude candidacy; single-fraction high-dose SBRT (e.g., 1200–1600 cGy x1) or other established regimens consistent with ASTRO guidance are planned.Life expectancy >3 months; recommended dose 1200–1600 cGy x1 for nonspine
From Nguyen RCT and ASTRO guideline
SBRT/SRS for Spine and Reirradiation
Covered when ALL of the following are met
SBRT for spine and reirradiation: Prior to RT, assess spine stability and need for surgical decompression; exclude active spinal cord or cauda equina compression requiring surgery; use established spine SBRT regimens (e.g., 24 Gy in two fractions or other validated multifraction regimens) or other regimens with similar BED, and document prior RT dose and interval when considering reirradiation; selection should respect trial eligibility limitations (e.g., limited number of contiguous vertebrae, absence of unstable fractures).Document prior RT, evaluate stability; typical spine SBRT example 24 Gy in 2 fx
From ASTRO guidance and randomized trials
SRS for Brain Metastases
Covered when ALL of the following are met
SRS for brain metastases: SRS is appropriate for patients with limited brain metastases (evidence from randomized trials supports SRS alone for 1–3 lesions with reduced cognitive decline versus WBRT) and may be considered for selected patients with up to 10 metastases based on observational data; selection should consider histology, brain metastasis velocity, extracranial disease status, performance status, and cumulative intracranial tumor volume; single-fraction or multifraction prescriptions selected per lesion size and location.Typically ≤3 lesions per RCT support; observational evidence up to 10 lesions
From randomized and observational brain metastasis studies and guidelines
SRS for intact brain metastases
Covered when consistent with guideline recommendations and patient selection described below:
SRS for intact brain metastases: Patient has ECOG 0–2 and up to four intact brain metastases (strong recommendation); SRS may be conditionally considered for 5–10 metastases; single-fraction SRS (2000–2400 cGy) recommended for lesions <2 cm, with multifraction options (e.g., 2700 cGy in 3 fx or 3000 cGy in 5 fx) for larger lesions or when fractionation is preferred; absence of diffuse disease or diffuse leptomeningeal metastases required.Up to 4 lesions (strong); 5–10 lesions (conditional); size-based dose thresholds per guidelines
From ASTRO and NCCN guidance
Adjuvant WBRT vs observation
Adjuvant therapy after surgery or radiosurgery:
Postoperative/radiosurgery setting: Adjuvant whole-brain radiotherapy (WBRT) reduces intracranial relapse and neurologic deaths compared with observation but does not improve duration of functional independence or overall survival; decisions regarding adjuvant WBRT should weigh intracranial control benefits against risks of cognitive decline and consider SRS to the surgical cavity when preservation of neurocognition is a priority.WBRT example 30 Gy in 10 fractions
From EORTC randomized trial and guideline interpretations
SRS for skull-base chordoma/chondrosarcoma
Skull-base chordoma and chondrosarcoma:
SRS as adjuvant or salvage therapy: SRS/GKRS may be used as primary, adjuvant, or salvage therapy for skull-base chordomas and chondrosarcomas, particularly for smaller residual volumes (tumor volume <20 ml associated with better local control); consider marginal doses of at least ~15 Gy and multidisciplinary planning after maximal safe resection.Tumor volume <20 ml associated with better control; marginal dose ≥15 Gy suggested
FSRT or SRS for residual/recurrent craniopharyngioma: Fractionated stereotactic RT or stereotactic radiosurgery may be used for residual or recurrent craniopharyngiomas to achieve high rates of tumor control and potential visual/clinical benefit; outcomes vary with tumor volume and completeness of coverage and hypopituitarism risk exists and should be monitored.Typical SRS median prescription ~12–13 Gy; FSRT regimens and outcomes reported with high 3-year PFS
From systematic reviews and case series
SBRT for primary liver tumors
Definitive SBRT for hepatocellular carcinoma and intrahepatic cholangiocarcinoma:
SBRT for solitary small HCC: SBRT is covered for solitary recurrent or unresectable HCC (≤5 cm, with greater benefit reported for ≤2 cm) in patients with preserved liver function (e.g., Child-Pugh A) and good performance status; typical regimens include 45–60 Gy in three fractions in trials, and SBRT showed superior local progression-free survival versus RFA in randomized data for small tumors.Tumor size ≤5 cm (trial eligibility); Child-Pugh A; typical 45–60 Gy in 3 fx reported
From randomized and phase II trial data and guidelines
SBRT for intrahepatic cholangiocarcinoma: SBRT may be considered for unresectable intrahepatic cholangiocarcinoma when dose constraints can be met, often delivered as ~45 Gy in 3–5 fractions; evidence is limited and primarily retrospective but supported by guideline recommendations to consider EBRT/SBRT in selected cases.Dose ~45 Gy in 3–5 fractions commonly reported
From systematic reviews and NCCN/ASTRO guidance
Covered Indications
Covered when supported by evidence and guideline recommendations as follows
SBRT for liver-confined HCC/IHC: SBRT is covered for liver-confined HCC or unresectable intrahepatic cholangiocarcinoma in patients who are not candidates for curative therapies or when catheter-based therapies are being considered; choice of dose/fractionation should account for tumor size, location, and baseline liver function and be delivered where normal tissue constraints can be met.Tumor size and Child-Pugh class inform appropriateness; typically 3–5 fractions
From ASTRO/ISRS/NCCN guidance and trials
SBRT for early-stage NSCLC: SBRT is covered for medically inoperable or high operative risk patients with stage I (T1-T2 N0 M0) NSCLC with tumor ≤5 cm, using regimens achieving high BED (e.g., BED≥100 Gy) and adhering to central versus peripheral constraints; multidisciplinary evaluation by thoracic surgery advised for operability assessment.Tumor ≤5 cm; BED ≥100 Gy associated with better local control
From RTOG 0236, Onishi, and ASTRO/NCCN guidance
Covered when ALL of the following are met
Coverage supported when clinical criteria and guideline recommendations are met
NSCLC stage I definitive SBRT: Biopsy-confirmed stage I (T1–T2 N0 M0) NSCLC in medically inoperable patients or those who decline surgery after thoracic surgery consultation; SBRT delivered with appropriate BED (typically ≥100 Gy) and technique, with operability assessment documented and multidisciplinary discussion when applicable.Tumor ≤5 cm; BED ≥100 Gy
From RTOG 0236, Onishi, ASTRO and NCCN
Pancreatic adenocarcinoma (BRPC/LAPC): SBRT may be covered as part of multimodality therapy for borderline resectable or select locally advanced pancreatic cancer after induction systemic chemotherapy to facilitate resection or as definitive local therapy when used with appropriate systemic therapy; regimens and sequencing per guideline recommendations should be documented.Typical regimens around 30 Gy in 5 fractions or varied fractionation per guideline
From ASTRO and NCCN guidance
Evidence-based coverage considerations (summary)
Coverage considerations reflected by clinical evidence and guideline recommendations in these excerpts (partial):
Prostate cancer definitive SBRT: SBRT/ultrahypofractionation is an accepted option for localized prostate cancer across risk groups when delivered with appropriate technology and expertise; randomized trial evidence demonstrates noninferiority for failure-free survival with comparable late toxicity, though acute urinary/bowel symptoms and dose-related late GU toxicity should be considered.See trial regimens (e.g., 42.7 Gy in 7 fx; 5-fraction SBRT regimens)
From randomized trials and meta-analyses
Renal cell carcinoma SBRT: SBRT can be considered for primary renal cell carcinoma in medically inoperable patients or those who decline surgery with dosing dependent on tumor size (e.g., ≤4–5 cm: 26 Gy x1; >4–5 cm: 42–48 Gy in 3 fx or 40 Gy in 5 fx if OAR constraints prevent 3 fx) and multidisciplinary decision documented.Size-based dosing per ISRS guidance
From FASTRACK II and ISRS guidance
Consolidative SBRT/SABR for extracranial oligometastatic disease
Covered when ALL of the following are met
Patient selection for consolidative SBRT/SABR: Patient has extracranial oligometastatic disease (commonly 1–5 metastatic lesions) with controlled or stable primary tumor and no progression after appropriate systemic therapy where indicated; all sites are amenable to safe stereotactic radiation delivered within normal tissue constraints.Typically 1–5 lesions; durable local control aim ≥85% at 2 years
From ARS, ASTRO/ESTRO, and ISRS recommendations
Multidisciplinary decision and intent: Treatment decision documented after multidisciplinary tumor board discussion with intent of definitive/ablative local therapy (not purely palliative) and staging imaging confirming extent of disease.
Implementation remark from guidelines
Feasibility and normal tissue constraints: Dose and fractionation are feasible given lesion location and size, and normal tissue constraints can be met (exercise caution for ultracentral lung lesions and critical serial OARs); simultaneous treatment of 2–5 pulmonary metastases may be considered if constraints permit.
SRS for select skull-base and vascular benign lesions
Covered when ALL of the following are met
SRS for glomus jugulare tumors: SRS may be used as primary or alternative local therapy for glomus jugulare tumors with evidence of high tumor control (~93–97% aggregate) and symptomatic improvement; candidacy determined by tumor size, location, and prior treatments with multidisciplinary evaluation.
From systematic reviews and multicenter series
SRS for cavernous sinus/orbital hemangiomas: SRS is an appropriate option for cavernous sinus and orbital hemangiomas with reported tumor regression and symptomatic improvement using margin doses commonly ~12–15 Gy while maintaining optic nerve dose constraints (e.g., <9 Gy where applicable).Median margin doses reported ~12.6–14.5 Gy; optic nerve constraints <9 Gy
From case series and pooled analyses
ISRS recommendations for intracranial cavernous malformations
ISRS guideline recommendations for intracranial cavernous malformations (ICMs):
SRS recommended for symptomatic/at-risk ICMs: For surgically inaccessible or eloquently located ICMs with prior symptomatic hemorrhage, SRS is recommended to reduce risk of subsequent hemorrhage (conditional, low-quality evidence).
ISRS systematic review guidance
SRS for epilepsy due to ICM: For ICM-associated epilepsy refractory to medication, SRS is recommended with intent to improve seizure control (conditional recommendation).
ISRS guideline
Asymptomatic ICM: SRS is not typically recommended for asymptomatic ICMs.
ISRS guideline
AVM SRS — repeat, staged, and predictors of outcome
Evidence on SRS for AVMs and repeat/staged SRS:
Repeat SRS for residual/recurrent AVM: Repeat SRS is a viable option for incompletely obliterated AVMs after initial SRS, achieving pooled obliteration rates in meta-analyses (~60% for repeat SRS) with acceptable complication rates; selection favors smaller residual volume and lower SM grade.Mean follow-up ~45 months reported in meta-analysis
From Maroufi et al. and multi-center series
Predictors and staged SRS: Smaller residual volume, lower Spetzler–Martin grade, and higher margin dose predict better obliteration; staged or volume-staged SRS may be used for large AVMs with recommended minimum margin doses (≈17 Gy) in many series and may require multiple procedures.Minimum margin dose often ≥17 Gy for staged approaches
From Kano and multicenter reports
Cavernous sinus and orbital hemangiomas
SRS for cavernous sinus and orbital hemangiomas:
SRS effective for cavernous sinus/orbital hemangiomas: Small series report consistent tumor regression and symptomatic improvement with SRS for cavernous sinus and orbital hemangiomas using median margin doses ~12.6–14.5 Gy and maintaining optic nerve dose constraints; long-term safety and efficacy documented in multicenter reports.Median margin doses ~12.6–14.5 Gy; optic nerve dose <9 Gy where applicable
From Lee et al. and Khan et al.
Meningioma — efficacy, risks, and guideline stance
SRS for benign meningiomas (noncavernous and parasellar/sellar):
High tumor control rates with SRS: SRS provides high local control and progression-free survival for selected benign intracranial meningiomas with typical single-fraction marginal doses between 12–16 Gy and long-term imaging control rates high in large series (e.g., 5- and 10-year PFS often >88–95% in selected cohorts).Typical margin dose 12–15 Gy single fraction
From large multicenter series and ISRS review
Risk factors for worse outcomes or complications: Factors associated with worse tumor control or higher complication rates include larger tumor volume, prior surgery or radiation, parasagittal/convexity location, male sex, and margin dose <13 Gy.
From Pollock, Sheehan, and Santacroce analyses
ISRS recommendation for noncavernous sinus benign meningiomas: ISRS supports SRS as a primary option for many intracranial noncavernous sinus benign meningiomas based on class III evidence (recommendation level II), with typical single-fraction prescriptions of 12–15 Gy.
Benign intracranial meningioma and related indications
SRS/SRS-based therapy is supported by retrospective series and ISRS review for control of selected benign intracranial meningiomas when delivered with typical single-fraction marginal doses (12–15 Gy).
Meningioma SRS candidate: Patient has an imaging-defined or histologically confirmed benign intracranial meningioma appropriate for radiosurgery (small-to-moderate volume, favorable location) and the plan prescribes an appropriate marginal dose (commonly 12–15 Gy single fraction); evidence shows high medium- to long-term tumor control in large series with acceptable morbidity.Dose ~12–15 Gy single fraction; imaging follow-up ≥24 months used in key series
From Santacroce et al. and ISRS guidance
Pineal region tumors
SRS (GKRS) can achieve local control in a heterogeneous set of pineal region tumors, with outcomes strongly dependent on histology and lesion grade.
Pineal tumor SRS consideration: Patient has a pineal region tumor with histologic diagnosis or well-supported presumptive diagnosis; SRS planning documents marginal dose (median reported ~14–15 Gy) and acknowledges that outcomes vary markedly by histology (e.g., pineocytoma vs pineoblastoma); decision informed by multidisciplinary review and intent to preserve neurologic/visual function.Typical marginal dose ~14–15 Gy reported
From multi-center series and reviews emphasizing histology-dependent outcomes
Pituitary adenoma (nonfunctioning and secretory)
SRS is an effective option for residual or recurrent pituitary adenomas; hypopituitarism is a common long-term toxicity requiring monitoring.
Pituitary SRS candidate scenarios: Patient has residual or recurrent nonfunctioning pituitary adenoma after prior surgery, or selected secretory adenoma scenarios where SRS is chosen as primary or salvage therapy; reported tumor control ~92% with pooled risk of new hypopituitarism ~13–21%; visual and cranial nerve injury rates low but should be monitored and documented.Mean follow-up ~60 months in meta-analyses; typical median SRS dose ~15 Gy
SRS and related stereotactic reirradiation approaches are used as salvage therapy for recurrent WHO grade III–IV gliomas with modest median PFS/OS; selection should consider prior therapies, expected benefit, tumor volume, and performance status.
Recurrent malignant glioma salvage SRS: Patient has recurrent WHO grade III–IV glioma with documented prior treatments; provide tumor volume, KPS, and planned dose/fractionation because outcomes correlate with these factors (e.g., better OS with KPS ≥80, smaller tumor volume <15 cm³); reported median OS after stereotactic reirradiation ~8–11 months and median PFS ~6–7 months; discuss risk of radionecrosis and corticosteroid dependence.KPS and tumor volume key selection factors; example regimens include 25 Gy in 5 fx
SRS has been evaluated for drug-resistant epilepsy, essential tremor, and some movement disorders with variable efficacy compared to open surgical options; evidence includes systematic reviews and limited RCT data for epilepsy.
Functional SRS candidate considerations: For drug-resistant mesial temporal lobe epilepsy, open surgical options (ATL, SAH) have higher seizure-free rates than SRS, but SRS may be considered for patients who are not surgical candidates; for essential tremor SRS demonstrates substantial response rates with variable latency to effect; decisions require multidisciplinary discussion and patient counseling on comparative efficacy and risks.Seizure-free rates and comparative outcomes vary by procedure; evidence limited
From RCTs and systematic reviews
Condition-specific coverage considerations
Selected coverage-relevant conclusions and criteria from trials and guidelines
Recurrent gliomas: SRS/FSRT may be reasonable as salvage reirradiation for recurrent high-grade glioma in selected patients (younger age, KPS ≥80, smaller tumor volume <15 cm³) with modest expected survival benefit; document selection rationale and expected goals of care.Selection based on KPS, tumor volume, prior therapy
From multiple series and NCCN guidance
Spinal metastases - pain control: Randomized and pooled data show varying results; some trials demonstrate improved pain response or complete pain response with SBRT versus cEBRT (example: 24 Gy in 2 fx), whereas others do not; selection should consider performance status, limited number of vertebral levels, absence of instability or neurologic compromise, prior RT, and life expectancy.Typical eligibility excludes spinal instability and extensive vertebral involvement
From randomized trials and meta-analyses
Evidence summaries and guideline recommendations
Evidence and guideline context for selected indications
Uveal Melanoma Evidence: Systematic reviews and single-arm series report high local control and eye preservation with stereotactic approaches for uveal melanoma but note substantial risks of radiation-related ocular complications; selection should be individualized and performed in experienced centers.
From systematic reviews and institutional series
Trigeminal Neuralgia Guidance: NICE recommends SRS for trigeminal neuralgia when standard clinical governance, consent, and audit arrangements are in place and patient selection is conducted by a multidisciplinary team experienced in trigeminal neuralgia; procedures should be performed in specialized centers.
From NICE guidance
Proven and Medically Necessary Indications (selected revised/added items)
Policy revised list of proven and medically necessary indications; select added or revised indications include:
Added - Non-spine bone metastasis: Bone metastasis (non-spine) when symptomatic and treated in up to five fractions is added as a proven/medically necessary indication.Fractions ≤5
Policy revision noted 02/01/2026
Added - Neurologic conditions: Neurologic conditions (epilepsy, Parkinson's disease, essential tremor) refractory to medical therapy and/or invasive surgical interventions are added to the proven/medically necessary list when criteria are met.
Policy revision noted
Added - Spinal lesions (palliative): Palliative treatment of symptomatic spinal bone metastasis using five fractions or less, without spinal cord or cauda equina compression, and primary spinal lesions not amenable to surgery or 3D conformal techniques are added/revised as proven/medically necessary.
Individuals with a diagnosis of lymphoma or germ cell tumor are explicitly excluded from the newly diagnosed brain metastasis stereotactic therapy indication. This exclusion appears in the brain metastasis criteria and is reiterated in the policy revision notes clarifying updated brain metastasis coverage criteria.
Prior treatments or conditions that were trial exclusions and may render SBRT/SRS inappropriate (and thus raise coverage risk) include: prior radiation to the intended treatment site, untreated spinal cord compression, pathologic fracture at the target site, and recent radioactive isotope therapy within 30 days. These elements should be documented and considered during prior authorization and medical necessity review.
Small cell lung cancer (SCLC) was excluded from the EORTC randomized trial cited for adjuvant WBRT versus observation; therefore, trial-derived recommendations about WBRT versus observation do not directly apply to SCLC. The policy revision notes also document changes to exclusion lists for brain metastasis indications, clarifying small cell carcinoma was removed from certain exclusions and highlighting the need to consider SCLC-specific evidence separately when applying these criteria.
Evidence supporting SBRT for intrahepatic cholangiocarcinoma (IHC) is limited and largely derived from retrospective series. While the policy includes unresectable intrahepatic bile duct cancer as a definitive-treatment indication, reviewers should note the smaller, retrospective evidence base and consider dose-constraint feasibility and patient selection when assessing medical necessity.
ASTRO guidance discourages using SBRT as a substitute for surgery in standard-operative-risk stage I NSCLC patients outside of clinical trials. SBRT may be considered for high-operative-risk or inoperable patients, but routine replacement of indicated surgery with SBRT without documented high operative risk or trial enrollment is not recommended.
Treatments that cannot meet anatomic or organ-at-risk constraints (for example, renal tumors abutting the bowel or masses exceeding size thresholds specified in guidelines/studies) may be considered not amenable to SBRT. Such situations (including tumors larger than trial or guideline size limits) carry a risk of noncoverage if safe delivery of stereotactic doses cannot be demonstrated.
Consolidative radiotherapy (including SBRT/SABR) is not generally recommended outside clinical trials for patients with six or more metastatic sites. Consolidative local therapy recommendations in guidelines and appropriateness criteria typically apply to patients with up to five metastatic lesions; treating six or more sites with consolidative intent may therefore be considered investigational outside trial settings.
ISRS guidance states that SRS is not typically recommended for asymptomatic intracranial cavernous malformations (ICMs). The guideline conditions SRS primarily for surgically inaccessible or eloquently situated ICMs with prior symptomatic hemorrhage or for medically refractory epilepsy caused by an ICM; asymptomatic lesions are not usual candidates for SRS per ISRS.
ISRS recommendations distinguish cavernous sinus meningiomas and cavernous-sinus–region lesions from noncavernous sinus benign meningiomas; guidance and outcomes for noncavernous sinus lesions (typical single-fraction marginal doses ~12–15 Gy) may not be directly generalizable to cavernous sinus locations, which the ISRS review addresses differently.
Key spinal SRS/SBRT trial eligibility criteria that affect applicability include exclusion of patients with spinal instability or vertebral compression fractures with >50% height loss, limits on the number of contiguous involved vertebrae (e.g., >3 cervical or >4 thoracic/lumbar/sacral contiguous vertebrae excluded in some trials), and restrictions on the number of treatment sites or visceral metastases (some trials excluded patients with >2 visceral metastases). These trial criteria should inform selection and prior-authorization decisions for spinal stereotactic treatments.
For several indications the evidence base is limited by retrospective designs and single-arm studies. Examples include many series of CyberKnife for uveal melanoma and SBRT cohorts for intrahepatic cholangiocarcinoma; these limitations should be considered in coverage decisions and when assessing expected benefit and documentation sufficiency.
The policy revision restates exclusions for brain-metastasis stereotactic indications and reiterates that individuals with lymphoma or germ cell tumor are excluded from certain brain metastasis stereotactic therapy indications. This exclusion is emphasized in the updated coverage criteria language.
Operational coding caveat: the policy notes that HCPCS code G0563 is not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered under the New Jersey Medicaid Program. Providers should verify state Medicaid fee-schedule coverage before billing under G0563.
Coverage under this policy is subject to applicable federal, state, and contractual benefit plan requirements. Inclusion of a procedure code in the policy does not itself guarantee coverage; benefit determination must follow the governing federal/state/contractual terms and applicable law.
Listing a procedure or HCPCS/CPT code in the policy is for reference only and does not imply that the service is covered or payable. Reimbursement is determined by the member’s specific benefit plan and applicable federal, state, or contractual rules.
Randomized trial evidence does not support routine use of adjuvant whole-brain radiotherapy (WBRT) after local therapy solely to improve survival or duration of functional independence. EORTC trial data show WBRT reduces intracranial relapse and neurologic deaths but did not improve overall survival or duration of functional independence, making WBRT a consideration of intracranial control versus cognitive outcomes rather than an automatic survival-improving adjuvant.
The referenced randomized data conclude that WBRT does not improve overall survival or duration of functional independence when used solely for those endpoints after surgery or radiosurgery for a limited number of brain metastases; WBRT’s principal benefit was intracranial relapse reduction at the cost of greater cognitive decline.
Although the policy does not state an explicit 'not medically necessary' determination in every excerpt, lack of supporting evidence or inability to meet dose/normal-tissue constraints (for example in liver or large tumors) may preclude coverage or render a request non-preferred. Reviewers should require documentation that dose constraints and selection criteria can be met before approving SBRT for such cases.
ASTRO specifically cautions against substituting SBRT for surgery in operable, standard-risk stage I NSCLC patients outside the context of a clinical trial. This guidance is intended to preserve surgery as the standard of care in operable patients unless a high operative risk is documented or trial participation is noted.
Surgery remains the standard of care for operable renal tumors. SBRT/SABR is an option for patients who are medically inoperable or decline surgery, but offering SBRT instead of indicated surgery without documentation of inoperability or high operative risk is not supported by the cited evidence and guidelines.
Intensive monitoring alone after colorectal cancer resection has not demonstrated an overall survival benefit in pooled randomized trials; earlier detection of metastases via intensified surveillance did not translate into improved OS in the randomized evidence cited, which informs expectations for surveillance-related interventions.
Re-irradiation or stereotactic approaches for recurrent malignant gliomas should be supported by documentation of reasonable expected benefit based on performance status, tumor volume, prior treatments, and prognosis. The literature reports modest median overall survival (e.g., median OS ~8.4 months with CyberKnife in WHO grade IV series) and nontrivial risks (radionecrosis, steroid dependence), so clear selection rationale is required for re-irradiation authorization.
CyberKnife series for uveal melanoma are predominantly single-arm and retrospective; limitations include lack of parallel comparators and heterogeneous cohorts. These evidence limitations should be acknowledged when assessing expected benefit and documentation adequacy for ocular SBRT/SRS.
The prior policy restriction limiting palliative spinal SBRT to ≤2 fractions has been removed. The revised policy allows up to five fractions for palliative spinal bone metastasis when the coverage criteria and clinical selection requirements are met.
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.
1–10 of 17
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Covered CPT CodesCPT
No codes listed
Representative SRS/SBRT CPT-related codesCPT
77373
Stereotactic radiosurgery, treatment delivery
77372
Special physics consultation
77338
Beam-shaping devices or similar (example planning); included as ancillary codes often used with SRS/SBRT
Covered CPT Codes (additional)CPT
No codes listed
Codes referenced in this sectionmixed
No codes listed
FDA device product codesmixed
MUJ
FDA product code referenced for SBRT/SRS devices
IYE
FDA product code referenced for SBRT/SRS devices
Applicable Codes / NJ Medicaid noteHCPCS
G0563
HCPCS code G0563 noted as not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program
Applicable HCPCS codes with NJ Medicaid noteHCPCS
G0563
HCPCS code G0563 — noted as not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program.
Performance status
Required performance statusKarnofsky Performance Status (KPS) ≥ 70 OR ECOG performance status 0–2
Applies toNewly diagnosed and repeat brain metastasis indications where performance status is specified
Role in selectionUsed to document ability to tolerate definitive or repeat stereotactic therapy and expected benefit
Cumulative brain metastasis tumor volume
Cumulative BM tumor volume threshold
Prior Authorization, Documentation, and Operational Guidance
Prior Authorization
Prior Authorization and Codes (Reference)
Prior authorization is required for stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) as specified under plan terms. The codes listed in the policy Applicable Codes section are provided for reference only and do not guarantee coverage or payment. Providers must follow UnitedHealthcare prior authorization processes and submit the applicable CPT/HCPCS/other procedure codes when requesting review.
Providers must verify prior authorization (PA) requirements and submit requests via UnitedHealthcare’s designated PA portal or call center.
Include all applicable procedure and diagnosis codes from the policy Applicable Codes list when requesting PA; listing of a code in the policy is not a guarantee of coverage.
Prior Authorization
Prior Authorization Guidance
Policy Definitions and Terminology
Definitive Treatment
Definition (Definitive Treatment)Radiation treatments for cancer delivered with curative intent
Revision noteDefinition updated in this policy revision (refer to definitions section for exact revised wording)
Clinical implicationUsed to distinguish definitive/curative stereotactic regimens from palliative or salvage intent
Oligometastatic Disease (OMD)
Definition (Oligometastatic Disease, OMD)A limited metastatic state in which eradication of all sites of disease could result in long-term survival or cure; commonly defined as one to five metastatic lesions
Policy applicationPolicy requires up to five metastatic lesions, controlled primary (often ≥3 months), KPS ≥70 or ECOG 0–2, and lesion size ≤5 cm for eligibility
Background and Clinical Context
Stereotactic body radiation therapy (SBRT), also called stereotactic ablative radiotherapy (SABR), delivers highly conformal, high-dose radiation in a small number of fractions (typically up to 5 fractions) to extracranial targets, allowing high per-fraction doses while limiting dose to adjacent normal tissues. Stereotactic radiosurgery (SRS) refers to highly precise, usually single-fraction treatment for intracranial targets; fractionated stereotactic approaches (FSRT) use 2–5 fractions when fractionation is preferred for larger lesions or to meet organ-at-risk constraints.
Policy Changes and Revision Notes
2026-02-01revisionLatest
Policy revised: applies to individuals 19 years and older; SRS/SBRT covered without further review for individuals younger than 19; added and revised proven/medically necessary indications including non-spine bone metastasis (symptomatic, up to 5 fractions), neurologic conditions refractory to treatment, and expanded spinal lesion criteria.
2026-02-01revision
Revised brain metastasis criteria to require absence of diffuse brain metastases and absence of diffuse leptomeningeal metastases; removed small cell carcinoma from the exclusion list (now excludes lymphoma and germ cell tumor only).
2026-02-01
Policy Summary
PayerUnitedHealthcare
PolicyStereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for New Jersey Only)
Policy CodePolicy CS180NJ.F
Change TypeMaterial revisions and additions
Effective DateFeb 1, 2026
Next Review Date
Key ActionFollow payer prior authorization processes and document indication, prior radiation, performance status, and planned dose/fractionation when requesting SRS/SBRT.
SBRT (five-fraction regimens) is an acceptable definitive option for low- and intermediate-risk localized prostate cancer when delivered with validated techniques and appropriate expertise; counsel on efficacy and toxicity tradeoffs per trial evidence.
Use trial-validated regimens (e.g., PACE-B, ultrahypofractionation examples)
From PACE-B, Widmark, and systematic reviews
Early-stage (T1-2N0M0) SCLC: SABR/SBRT may be used for inoperable, node-negative early-stage SCLC often in combination with chemotherapy per guideline recommendations; regimens reported in literature around 50 Gy in 3–5 fractions and selection should follow NCCN/ASTRO guidance.Regimens reported ~50 Gy in 3–5 fx
From systematic reviews and guideline excerpts
From ISRS/ASTRO/ESTRO guidance
Dose ~12–15 Gy; follow-up imaging >24 months in key series
From ISRS guideline and meta-analyses
Spinal lesions - local control and safety:
Systematic reviews report high pooled pain response (~83%), one-year local control ~94%, low radiation-induced myelopathy, and vertebral fracture risk ~9%; consider vertebral fracture risk and prior RT dose constraints when planning SBRT.
Consider fracture risk and prior RT constraints
From Guninski et al. meta-analysis
Trigeminal neuralgia secondary to tumors: SRS provides meaningful pain relief for tumor-related trigeminal neuralgia with pooled adequate pain relief ~73% and adverse effects ~14%; procedures should be performed in specialized centers with multidisciplinary oversight.Specialized center and multidisciplinary selection
From condition-specific reviews and NICE guidance
Uveal melanoma: SRS/CyberKnife yields high rates of local control and eye preservation in uveal melanoma (3-year local control ~89% for CyberKnife; pooled GKRS control ~96%) with notable ocular morbidity (radiation retinopathy, glaucoma, retinal detachment); selection should weigh ocular morbidity risk and consider dose constraints for ocular structures.Consider tumor size and dose (e.g., ≥45 Gy in 3 fx for larger tumors)
From systematic reviews and case series
Fractions ≤5
Policy revision noted
Newly Diagnosed Brain Metastasis (revised): Coverage requires absence of diffuse brain metastases and absence of diffuse leptomeningeal metastases; individuals with lymphoma or germ cell tumor are excluded (small cell carcinoma removed from exclusion).
Policy revision noted
Repeat Stereotactic Radiation Therapy for Brain Metastasis (revised): Requires absence of diffuse leptomeningeal metastases; extracranial disease is well-controlled or accessible/effective systemic options exist; prior numeric limit on total brain metastases treated in past 12 months removed.
Policy revision noted
Definitive Treatment (revised): Added intrahepatic bile duct cancer (cholangiocarcinoma) for unresectable tumors to the definitive treatment criteria when lesion is medically inoperable or individual is a non-optimal surgical candidate.
Policy revision noted
Extracranial Oligometastatic Disease (revised): Individual has up to five metastatic lesions and performance status KPS ≥70 or ECOG 0–2 as a revised limit for OMD eligibility.Lesions ≤5; KPS ≥70 or ECOG 0–2
Policy revision noted
Less than 15 cubic centimeters (cc)
ContextOne of the criteria for newly diagnosed brain metastasis eligibility (alternatively up to 10 lesions)
UseGuides selection for SRS/FSRT to limit overall treated intracranial tumor burden
Number of brain metastases
Guideline-supported countEvidence and policy support SRS for 1–3 brain metastases with randomized data; observational data support SRS alone for up to 10 lesions in selected patients
Policy numeric limit (newly diagnosed)Has up to 10 lesions (or cumulative tumor volume <15 cc) as an eligibility criterion
Selection factorsClinical selection should also consider histology, extracranial disease control, and performance status
Lesion size for oligometastatic disease
Maximum lesion size for OMDEach lesion ≤ 5 cm
ContextRequirement for extracranial oligometastatic disease eligibility (all lesions must be safely treatable)
Related constraintSBRT dosing and feasibility should be determined based on lesion size and normal-tissue constraints
SBRT fraction limit
SBRT course fraction limitEntire SBRT treatment course not to exceed 5 fractions
Typical intracranial FSRTSRS delivered in a single treatment or FSRT in 2–5 fractions for larger intracranial lesions
RationaleConsistent with SBRT/SABR definitions and device/coding descriptors for stereotactic courses
Number of brain metastases treated
Evidence-supported countsRandomized and guideline data support SRS alone for 1–3 lesions; observational cohorts (e.g., JLGK0901) support SRS alone in selected patients up to 10 lesions
Patient selection considerationsSelection should factor performance status, histology, brain metastasis velocity, and extracranial disease control
Safety noteHigher lesion counts may increase intracranial failure risk and require multidisciplinary review
Number of intracranial metastases for SRS
Recommended intracranial lesion counts for SRSSRS recommended for up to 4 intact brain metastases (strong recommendation); conditional recommendation for 5–10 lesions
Dose/fraction examplesSingle-fraction 2000–2400 cGy for lesions <2 cm; multifraction options include 2700 cGy/3 fx or 3000 cGy/5 fx
Clinical caveatPatient performance status (ECOG 0–2) and lesion characteristics guide application of recommendations
Tumor size threshold
Tumor-size outcome thresholds (HCC)HCC outcomes vary by tumor size; subgroup analyses differentiate tumors <3 cm versus ≥3 cm (and trials note particular benefit for very small tumors ≤2–3 cm)
NSCLC size distinctionDefinitive SBRT trials and guidance typically enroll stage I tumors ≤5.0 cm (T1–T2) for early-stage NSCLC
Clinical implicationTumor size informs choice of SBRT dose/fractionation, expected local control, and toxicity risk
Renal tumor size thresholds for SBRT dosing
Renal tumor dosing by sizeTumor ≤4–5 cm: 26 Gy in 1 fraction; Tumor >4–5 cm: 42–48 Gy in 3 fractions (or 40 Gy in 5 fractions if OAR constraints cannot be met)
ContextISRS recommended dose-regimens for primary renal cell carcinoma when SBRT is used as alternative to surgery in inoperable/high-risk patients
RequirementMultidisciplinary decision and attention to renal function and OAR constraints are required
Ultrahypofractionation regimen example (prostate)
Example ultrahypofractionation regimen (prostate)42.7 Gy delivered in 7 fractions
Trial contextRegimen used in randomized ultrahypofractionation trials comparing to conventional fractionation
ApplicabilityExample of ultrahypofractionation; selection depends on patient risk group and institutional protocol
Typical SRS marginal dose for benign intracranial tumors
Typical single-fraction marginal dose (benign intracranial tumors)Commonly 12–15 Gy in a single fraction for intracranial noncavernous sinus benign meningiomas and some pineal/pituitary lesions
Evidence basisISRS systematic reviews and large GKRS series report typical prescription margins in this 12–15 Gy range with high long-term control rates
MonitoringLower margin doses (<13 Gy) associated with increased progression risk in some series; dose selection should balance control and toxicity
Example fractionation for recurrent high-grade glioma re-irradiation
Example re-irradiation fractionation (rGBM)Median 25 Gy in five fractions reported in LINAC-based salvage series
ContextUsed in re-irradiation of recurrent high-grade gliomas where limited benefit expected and selection based on KPS, tumor volume, and prior therapies
Outcomes noteMedian OS after salvage stereotactic re-irradiation typically modest (~8–9 months) per series
Maximum metastatic lesions for OMD
Maximum metastatic lesions for OMD (updated)Up to 5 metastatic lesions
Policy changeExpanded extracranial oligometastatic disease allowance from up to 3 to up to 5 lesions in the revision
Selection considerationsPrimary tumor control, performance status (KPS ≥70 or ECOG 0–2), lesion size (≤5 cm), and feasibility to treat all lesions are required
Fractions for palliative bone metastasis treatment
Allowed fractions for palliative bone metastasisUp to five fractions for palliative treatment of symptomatic non-spine and spinal bone metastases when criteria are met
Pre-treatment assessmentEvaluate spine stability and need for surgery before initiating RT for symptomatic spinal metastases
PA requests should clearly document the clinical indication for SRS/SBRT, prior radiation to the treatment site, planned dose and fractionation, treatment intent (definitive vs palliative), and expected goals of care. Authorization decisions will consider guideline-supported indications, prior therapies, normal tissue constraints, and patient prognosis.
Expected PA elements: indication, prior RT to site (dates and doses), planned dose and fractionation with rationale, treatment intent, ECOG/PS, life expectancy estimate when relevant, and multidisciplinary discussion notes if available.
PA reviewers will compare the requested regimen and intent with guideline-recommended dose/fractionation for the specific indication.
Prior Authorization
PA for SRS/SBRT — Indication and Planned Dose
Authorization for SRS/SBRT will be based on the documented clinical indication and the planned dose and fractionation. Requests that do not match guideline-recommended intent or regimens, or that lack dose/fractionation details and supporting imaging, may be denied or returned for more information.
For intracranial SRS, provide lesion size/volume, number of lesions, target location, planned prescription dose and isodose line, and prior cranial RT history.
For extracranial SBRT, provide tumor histology (if required), lesion size, number of lesions, proximity to organs at risk (OARs), planned dose/fractionation, and imaging to support target delineation.
Prior Authorization
Consideration of Indication, Dose, and Lesion Factors
When assessing appropriateness, reviewers will consider indication-specific factors (e.g., operability for early-stage NSCLC, number and size of metastases, OAR proximity), recommended dose ranges, and lesion-specific risk factors that influence fractionation choice.
Single-fraction SRS doses for intracranial benign meningiomas often range 12–15 Gy; margin dose <13 Gy is associated with increased progression risk and should be documented if used.
For lung, liver, spine, and renal lesions, document tumor size/diameter, central versus peripheral location, and whether normal tissue constraints can be met to justify single- versus multifraction regimens.
Documentation Required
Clinical Information Required for Prior Authorization
The following clinical information is required to support PA for SRS/SBRT: histology or reason histology unavailable, prior treatments (surgery, systemic therapy, prior RT with doses), tumor size/volume, number of lesions, performance status, imaging, planned dose/fractionation, and multidisciplinary discussion when applicable.
Histology or clear rationale if biopsy not obtained.
Prior local/regional therapies including dates and doses (especially prior RT to same anatomic site).
Imaging: diagnostic and planning imaging demonstrating target(s) and relationship to OARs.
Document Indication, Prior RT, Performance Status, and Dose/Fractionation
PA submissions must document indication, prior radiation to the site (with dates and doses), performance status (ECOG/KPS), and the planned dose and fractionation. Randomized-trial-supported regimens or guideline-preferred regimens should be noted when applicable to support the request.
Include ECOG or KPS and estimated life expectancy where relevant to palliative versus definitive intent.
Cite trial- or guideline-supported dose/fractionation when used (e.g., SBRT 24 Gy in 2 fractions for painful spinal metastases per trial evidence).
Clearly state whether treatment is intended as consolidative, definitive, palliative, or salvage therapy and document prior systemic therapy response when relevant.
Prior Authorization
Prior Authorization and New Jersey Medicaid Note
This policy applies to individuals 19 years of age and older for coverage determinations; SRS/SBRT for individuals younger than 19 may be covered without further review per plan rules. Note: HCPCS code G0563 is not on the State of New Jersey Medicaid fee schedule and therefore may not be covered by NJ Medicaid; providers should confirm NJ Medicaid-specific billing rules before submission.
When treating New Jersey Medicaid members, verify whether G0563 is payable under the member’s plan; absence from the NJ Medicaid fee schedule may result in noncoverage.
Age applicability: include patient age on PA request; different administrative rules may apply for individuals <19.
Note
Verify Plan-Specific Requirements
Providers must verify plan-specific, federal, state, and contractual benefit requirements before submitting PA requests. In the event of any conflict between this policy and federal/state/contractual requirements, the federal/state/contractual terms govern coverage.
Check member benefit plan, state-specific mandates, and Medicaid fee schedules prior to scheduling services.
If external utilization management tools (e.g., InterQual®) are used by UnitedHealthcare for PA decisions, indicate in the submission any relevant InterQual criteria met.
Note
Implications of EORTC Trial on Adjuvant WBRT
The EORTC trial showed that adjuvant whole-brain radiotherapy (WBRT) after surgery or radiosurgery reduces intracranial relapse but does not improve overall survival and may impact neurocognitive outcomes. When requesting adjuvant WBRT or cavity-directed SRS, document the rationale considering neurocognitive risks and salvage strategy.
For resected brain metastases, document expected benefit of improved intracranial control versus potential neurocognitive harms when considering adjuvant WBRT.
If SRS to the surgical cavity is chosen instead of WBRT, include cavity size, dose/fractionation plan, and follow-up/salvage plans.
Documentation Required
Operability Assessment Impacts Appropriateness
Operability assessments influence appropriateness for SBRT. For early-stage NSCLC and primary renal tumors, document thoracic or urologic surgical evaluations or multidisciplinary determinations of inoperability when SBRT is requested as an alternative to surgery.
For stage I NSCLC, include thoracic surgeon consultation documenting operative risk or patient refusal of surgery.
For renal cell carcinoma, include biopsy confirmation when trial or guideline requires it and documentation of surgical contraindication or patient refusal.
Prior Authorization
Patient Selection Limits per Guidelines
Guidelines generally limit definitive local therapy to patients with a limited number of metastases. For oligometastatic indications, provide the number of metastases, imaging demonstrating extent of disease, and whether up-front systemic therapy was given with response assessment when applicable.
NCCN/ASTRO/ESTRO commonly support definitive local therapy for up to five metastases; many trials enrolled patients with one to two lesions — document how the patient aligns with trial populations.
For consolidative therapy after systemic therapy, document number of cycles, timing, and disease stability/progression.
Note
Dose-Related Progression Risk Noted
Dose selection can influence progression risk. For meningiomas and other histology-specific lesions, margin dose and fractionation correlate with long-term control; document rationale when doses below commonly reported thresholds are used.
Example: in meningioma series, margin doses <13 Gy were associated with higher progression risk—document clinical justification if prescribing <13 Gy.
If lower margin doses or alternative fractionation are chosen to meet OAR constraints, include dosimetric planning demonstrating constraints and anticipated BED.
Prior Authorization
Trial Eligibility Limitations Relevant to Spinal SRS/SBRT
Be aware of trial eligibility exclusions that may affect coverage for spinal SRS/SBRT (e.g., spinal instability, significant vertebral compression fracture, prior overlapping high-dose RT). PA should document exclusion criteria are absent or provide rationale if present.
Document Spinal Instability Neoplastic Score (SINS) and surgical evaluation when applicable prior to spinal SBRT.
If prior RT to the same spinal level was delivered, provide prior dose distribution and interval since prior RT to support reirradiation planning.
Billing Rule
Noncoverage Risk for HCPCS G0563 (NJ Medicaid)
HCPCS code G0563 is noted as not being on the State of New Jersey Medicaid fee schedule and therefore may not be covered for NJ Medicaid members. Providers should verify NJ Medicaid coverage and applicable billing rules before submitting claims.
When submitting claims for NJ Medicaid members, confirm whether G0563 is payable; if not, consider alternative billing codes as appropriate and document discussions with the payer.
In PA submissions for NJ Medicaid members, include NJ-specific coverage confirmation if available.
Note
Conflicts with Plan Terms
In cases where federal, state, or contractual plan terms conflict with this policy, the external requirements govern. Providers should confirm applicable regulatory or contractual obligations before proceeding with treatment.
If a state mandate or contractual term requires coverage beyond this policy, include that documentation in the PA request.
UnitedHealthcare reserves the right to modify policies; always check the member’s current plan documents and state regulations.
Documentation Required
Medical Record Requirements
Medical records supporting PA and any post-payment review must be complete, legible, and retained. Records should include history, physical exam, diagnostic test results, multidisciplinary discussion notes, operative reports, prior RT records, and radiation treatment planning documents.
Records must be made available upon request and should support medical necessity for the requested service.
Incomplete or missing documentation may result in denial or noncoverage.
Documentation Required
Clinical Eligibility Documentation for Liver SBRT
For liver SBRT, include tumor-specific eligibility and liver-function documentation: tumor size, number of lesions, prior local therapies, Child-Pugh score, KPS/ECOG, and planned dose/fractionation with expected normal liver and OAR doses. Dose constraints must be met or an explanation provided.
Provide Child-Pugh class and any recent laboratory values relevant to hepatic function.
Document prior treatments (ablation, TACE, surgery) and whether SBRT is first-line, consolidative, salvage, or alternative to other local therapies.
Documentation Required
Clinical Documentation to Support SBRT for Liver Tumors
Support SBRT for liver tumors with documentation of tumor size, location (segment, proximity to bowel/duodenum), prior local therapies, and dosimetric plans showing OAR constraints can be met. Image-guided RT planning and motion management strategies should be described.
Include planning CT/MRI and motion management (e.g., breath-hold, gating, fiducials) information.
If dose constraints cannot be met, provide alternative plan details or rationale for fractionation change.
Documentation Required
Operability and Risk Documentation
When SBRT is requested for thoracic lesions, provide the thoracic surgeon’s operability assessment when surgery is an option, and document risks that justify nonoperative management. For procedures replacing or deferring surgery, include multidisciplinary discussion.
Thoracic surgeon consultation note documenting anticipated operative mortality/risk and whether patient is high surgical risk, refuses surgery, or is medically inoperable.
For pancreatic and prostate SBRT used as part of multimodality care, document induction therapy and sequence of treatments.
Documentation Required
Documentation Expectations
Documentation expectations include biopsy or histologic confirmation when required by guideline or trial context, multidisciplinary decision notes, staging imaging, prior systemic therapy details, and targeted anatomic imaging used for planning and follow-up.
For indications where biopsy is required (e.g., renal trials), include pathology reports; if not obtainable, provide rationale and imaging-based justification.
For consolidative or salvage therapy, include evidence of disease stability or progression on recent imaging.
Note
Follow-up Imaging and Clinical Documentation
Include recommended follow-up imaging and clinical surveillance intervals in the treatment plan and PA submission when applicable. Routine post-treatment imaging schedules should align with guideline recommendations for the specific disease site.
Example: post-SBRT renal surveillance—cross-axial imaging of abdomen and chest imaging every six months as recommended by ISRS for primary RCC.
For intracranial lesions, document planned MRI follow-up intervals and neurocognitive/neurologic assessments.
Prior Authorization
Pre-Treatment Assessment for Spinal Metastases
For spinal metastases, assess spine stability and obtain surgical/spine specialist evaluation prior to SBRT when indicated. Document SINS, neurologic status, and whether spinal decompression or stabilization was considered or performed.
Document Spinal Instability Neoplastic Score (SINS) and whether surgery was recommended or performed.
If treating reirradiation cases, include prior RT fields, delivered doses, planning images, and interval since prior RT.
Note
Device Information
When device identity or clearance is relevant to the submission (e.g., specific stereotactic platforms), include device information. FDA product codes MUJ and IYE may be referenced for devices cleared for SRS/SBRT.
If the treating device or platform is material to the request, include make/model and clearance information.
Refer to FDA PMN database for device-specific documentation when requested by the payer.
Note
Check Plan Requirements
Before using this policy, verify federal, state, and contractual benefit plan requirements. UnitedHealthcare’s policies are informational and in the event of conflict, external requirements govern. Providers should confirm member-specific benefits and any state-mandated coverage prior to scheduling.
Verify member eligibility, benefit limitations, and any prior authorization or referral requirements.
Document confirmation of plan-specific requirements in the PA submission when relevant.
Note
Consideration of Prior/Alternative Therapies and Sequence of Care
Consider prior and alternative therapies and sequence of care when requesting PA. Document prior systemic therapy, ablation, embolization, surgery, or conventional RT and rationale for choosing SRS/SBRT at the planned time point.
For oligometastatic NSCLC or consolidative therapy, document number of systemic therapy cycles and response prior to local therapy.
For liver HCC, document prior ablation/embolization history and rationale for SBRT as first-line or salvage therapy.
Documentation Required
Sequence of Therapy Documentation
When part of multimodality care, document sequence of therapy (e.g., induction systemic therapy before consolidative SBRT, adjuvant/local therapy after resection). For pancreatic cancer and other sites where trial data guide sequencing, include dates and responses to prior treatments.
For consolidative RT after systemic therapy, document cycles given, imaging showing no progression, and timing of planned RT.
For pancreatic SBRT used as neoadjuvant or definitive therapy, include systemic therapy regimen and timing relative to SBRT.
Documentation Required
Surgery Preferred Before SBRT for Operable Renal Tumors
Surgery is the preferred approach for operable renal tumors. When SBRT is requested as primary therapy for renal cell carcinoma, include documentation of surgical evaluation and the reasons the patient is not a surgical candidate or declined surgery.
Include urology consultation and biopsy results where applicable.
If the patient declined surgery, include informed consent discussion and documentation of alternatives.
Documentation Required
Prior Surgery versus Primary SRS
For intracranial indications where prior surgery could be an alternative (e.g., benign cavernous sinus lesions), document prior surgical evaluation or a multidisciplinary rationale for choosing primary SRS instead of surgery.
Include neurosurgical consult notes and operative risk assessments when available.
If SRS is chosen as primary therapy, document multidisciplinary discussion and patient preference.
Note
Consideration of Alternative Surgical Therapies
In selected benign intracranial conditions, SRS may be an alternative to invasive surgery per consensus guidance. When proposing SRS as an alternative, include evidence of guideline or consensus support and documentation of multidisciplinary evaluation.
For functional indications (e.g., tremor) or cavernous sinus hemangioma, include prior medical therapy failure and multidisciplinary confirmation that SRS is appropriate.
Reference ISRS recommendations or other consensus guidance when applicable.
Prior Authorization
Consideration of RT Modality Prior to Authorization
Prior to authorization, consider RT modality choices (single-fraction SRS, multifraction SRS, SBRT, conventional EBRT) based on prognosis, prior RT doses, normal tissue risks, lesion size/location, and patient preferences. Document the rationale for the selected modality and regimen.
When choosing single-fraction versus multifraction schedules, include tumor and OAR considerations and expected BED to support the decision.
If choosing SBRT over conventional RT for palliation or definitive intent, document life expectancy, expected QOL impact, and guideline support.
Guideline basisDefinition and numeric threshold supported by ESTRO/ASTRO consensus and trial inclusion criteria
Brain Metastasis Velocity (BMV)
Definition (Brain Metastasis Velocity, BMV)BMV = cumulative number of new brain metastases developing after initial SRS divided by years since that SRS; used as a prognostic metric to stratify risk
Use in follow-up/selectionBMV categories (e.g., ≤3, 4–13, ≥14) inform prognosis and may impact decisions on repeat focal therapy versus WBRT
Clinical roleConsidered alongside lesion count, performance status, and extracranial disease in eligibility for SRS or repeat stereotactic therapy
SRS / SBRT
Definition (SRS / SBRT)Highly conformal, high-dose-per-fraction radiotherapy delivered in one or a few fractions for precise targeting of intracranial (SRS) or extracranial (SBRT) lesions
Fractionation examplesSRS often single fraction; FSRT 2–5 fractions; SBRT typically delivered in ≤5 fractions for extracranial targets
PurposeDelivers high biologic effective dose to the target while minimizing dose to adjacent normal tissue
Radiation-induced liver disease (RILD)
Definition (Radiation-induced liver disease, RILD)Serious hepatic toxicity associated with liver-directed radiotherapy; incidence is correlated with baseline liver function (e.g., Child-Pugh class)
RelevanceRILD risk influences patient selection and dose/fractionation for liver SBRT
DocumentationAssess baseline liver function (Child-Pugh) when considering SBRT for HCC or IHC
Peripheral versus central lung tumor
Definition (Peripheral vs central lung tumor)Peripheral lung tumors are located away from central thoracic structures; central tumors abut mediastinal structures and have different SBRT fractionation/toxicity considerations
Clinical implicationCentral/ultracentral location may require altered fractionation and caution due to higher OAR risk
Guideline noteASTRO guidance recommends surgeon evaluation for operability and tailored SBRT regimens based on location
Biologically effective dose (BED)
Definition (Biologically effective dose, BED)A dose metric used to compare hypofractionated regimens; higher BED correlates with improved local control in many SBRT series
ExampleOnishi NSCLC series reported median BED ~111 Gy associated with favorable local control
UseBED informs choice of regimen to achieve durable local control while managing toxicity
Medically inoperable / high operative risk
Definition (Medically inoperable / high operative risk)Patients evaluated by a thoracic surgeon and deemed at high operative risk or medically inoperable; SBRT may be considered when surgery is not appropriate
Documentation expectationOperability assessment by thoracic surgery should be documented when SBRT is used as definitive therapy for early-stage NSCLC
Guideline stanceASTRO recommends surgical evaluation and limits routine substitution of SBRT for operable patients outside trials
Ultrahypofractionation / SBRT
Definition (Ultrahypofractionation / SBRT)Delivery of high-dose radiation in a small number of fractions (examples include 42.7 Gy in 7 fractions or regimens delivered in 1–5 fractions) for definitive or metastasis-directed therapy
Example trialsWidmark ultrahypofractionation trial used 42.7 Gy in 7 fractions; prostate SBRT trials used five-fraction regimens
Clinical useRegimen selection depends on anatomic site, tumor histology, and normal-tissue constraints
Oligometastatic disease (typical 1–5 lesions)
Definition (OMD typical lesions)Oligometastatic disease is typically defined as 1–5 metastatic lesions with the primary tumor controlled or optional, and all metastatic sites safely treatable
Policy alignmentPolicy updated to require up to 5 lesions for consolidative SBRT/SABR per guideline/consensus recommendations
Implementation remarkDurable local control implementation target: minimum 85% local control at two years
Durable local control
Durable local control targetImplementation remark: minimum 85% local control at two years
UseBenchmark for evaluating SBRT regimens and expected outcomes in oligometastatic and definitive settings
Optimal outcome (AVM study)
Definition (Optimal outcome for AVM study)AVM optimal outcome defined as obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes
ImplicationUsed to assess success of SRS and repeat/staged SRS strategies for AVMs
Typical single-fraction prescription (meningioma)
Typical single-fraction prescription (meningioma)Commonly 12–15 Gy in a single fraction for intracranial noncavernous sinus benign meningiomas
EvidenceLarge GKRS series and ISRS reviews report this prescription range with high long-term tumor control rates
Hypopituitarism (post-SRS)
Definition (Hypopituitarism post-SRS)New or worsened pituitary hormonal deficiency following SRS for pituitary adenomas; pooled risk estimates reported around 13–21% depending on series
Monitoring implicationLong-term endocrine follow-up is required after pituitary SRS due to hypopituitarism risk
Local control (meningioma series)
Definition (Local control in meningioma series)Imaging-defined stable disease, regression, or absence of radiographic progression; large GKRS meningioma series report ~92.5% imaging control with long follow-up
UseOutcome metric for assessing efficacy of SRS in benign intracranial tumors
SBRT/SRS dose examples
Dose examples (SBRT/SRS)Nonspine single-fraction 1200–1600 cGy; spine 2400 cGy in two fractions; conventional palliative regimens include 800 cGy x1, 1600 cGy x2, 2000 cGy x5
ContextExamples drawn from ASTRO palliative RT guidance and used for planning and prior authorization documentation
Specialized center
Definition (Specialized center)A multidisciplinary, experienced center for management and selection of patients for SRS procedures; recommended for conditions like trigeminal neuralgia
Guideline basisNICE and ISRS guidance recommend multidisciplinary teams and specialized centers for complex stereotactic procedures
Definitive Treatment (updated)
Definitive Treatment (updated)Definition of 'Definitive Treatment' updated in this policy revision; refers to curative-intent radiation therapy per definitions section
OMD definition updatedPolicy revision updated the definition of OMD to align with consensus (1–5 lesions) and implementation remarks
Operational noteSee Definitions section of policy for exact revised wording
revision
Revised repeat stereotactic brain therapy criteria to require absence of diffuse leptomeningeal metastases, clarified extracranial disease requirement (well-controlled or accessible effective systemic options), and removed prior numeric limit on brain metastases treated in past 12 months.
2026-02-01revision
Expanded extracranial oligometastatic disease allowance from up to three to up to five metastatic lesions and clarified performance status language (KPS/ECOG thresholds reflected elsewhere in policy).
2026-02-01revision
Added intrahepatic bile duct cancer (cholangiocarcinoma) for unresectable tumors to Definitive Treatment criteria.
2026-02-01operational_note
Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria but does not guarantee coverage.
2026-02-01coding_note
Added notation across Applicable Codes sections that HCPCS code G0563 is not on the New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program.
Material change summary (effective 02/01/2026): the policy was revised to apply to individuals aged 19 years and older (with SRS/SBRT covered without further review for younger individuals), to expand and revise proven and medically necessary indications (including adding non-spine bone metastasis up to five fractions, neurologic conditions refractory to other therapies, expanded spinal lesion criteria), to update brain metastasis coverage language (adding requirements for absence of diffuse brain/leptomeningeal metastases and modifying exclusions), to expand extracranial oligometastatic disease limits from up to three to up to five metastatic lesions, to add intrahepatic bile duct cancer as a definitive-treatment indication for unresectable tumors, and to remove the previous 2-fraction limit for palliative spinal SBRT (now allowing up to five fractions when criteria are met).