ModifiedUnitedHealthcarePolicy CS180LA.E

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

Policy governing coverage and medical necessity criteria for SRS and SBRT for individuals aged 19 and older in Louisiana, as applied by UnitedHealthcare.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS180LA.E

Change TypeMaterial updates to age applicability, oligometastatic lesion limits, performance status wording, and documentation expectations

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of indication, performance status (KPS ≥70 or ECOG 0–2), prior RT history, and planned SBRT/SRS dose/fractionation.

SourceLink

POLICY UPDATE CHANGES

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.

Extracranial oligometastatic disease lesion count criterion revised from up to three metastatic lesions to up to five metastatic lesions.

Replaced performance status wording to 'KPS score greater than or equal to 70% or ECOG performance status of zero to two'.

Removed language indicating SBRT for palliative treatment of bone metastases of the spine is proven and medically necessary when using 2 fractions or less and there is no spinal cord or cauda equina compression.

Medical records documentation language expanded to specify records may be required to assess clinical criteria and must fully support medical necessity.

Updated definitions for Definitive Treatment and Oligometastatic Disease.

Noted HCPCS code G0563 is not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by the State of Louisiana Medicaid Program.

Updated Clinical Evidence and References sections and archived previous policy version CS180LA.D.

age ≥ 19

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applies to 19+ years

up to 5oligometastatic lesion limit

KPS ≥70 / ECOG 0-2performance status requirement

up to 10 / <15 ccbrain metastases lesion limits

≤ 5 fractionsSBRT fraction limit

G0563LA Medicaid code note

Coverage Criteria and Indications

Coverage Rationale — overarching indications

Stereotactic radiation therapy including SRS and SBRT is considered proven and medically necessary for the following indications when the specified criteria are met. Note: This policy applies to individuals 19 years of age and older. SRS/SBRT are covered without further review for individuals younger than 19 years of age.

Acoustic neuroma (vestibular schwannoma).

Bone metastasis (non-spine) when ALL of the following are met: - Symptomatic - Up to five fractions.

Brain metastasis when ANY of the following are met: - Newly diagnosed brain metastasis and ALL of the following are met: - 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 are treated in a single treatment for SRS or in two to five fractions for FSRT (fractionated stereotactic radiation therapy) - Individual is undergoing repeat stereotactic radiation therapy and ALL of the following are met: - Individual has a good performance status (KPS ≥ 70% or ECOG 0–2) - Absence of diffuse leptomeningeal metastases - Extra-cranial disease is well-controlled or there are accessible and effective systemic treatment options available - Life expectancy is greater than six months - All lesions are treated in a single treatment for SRS or in two to five fractions for FSRT - Retreatment after previous whole brain radiation therapy (WBRT) when clinically appropriate.

Covered indications and dose/fractionation guidance

Covered indications and dose/fractionation guidance (guideline- and trial-aligned):

Definitive treatment of the following when ALL listed criteria for the specific site are met: - Hepatocellular carcinoma (HCC) without evidence of regional or distant metastasis (see Liver SBRT group for evidence and dose guidance). - Intrahepatic bile duct cancer (intrahepatic cholangiocarcinoma) for unresectable tumors when unresectable and dose constraints can be met. - Non–small cell lung cancer (stage I or selected stage IIA) when ALL of the following are met: - Stage I or stage IIA with negative mediastinal lymph nodes - Tumor size ≤ 5 cm - Individual is medically inoperable or declines surgery after appropriate consultation. - Pancreatic adenocarcinoma without evidence of distant metastasis (use of adjuvant pancreatic SBRT is recommended only in trials/registries). - Prostate cancer without distant metastases (see oligometastatic criteria for metastatic contexts). - Renal cell carcinoma (stage I) when the individual is a non-optimal surgical candidate. - Small cell lung cancer (stage I or node-negative stage IIA) when medically inoperable or non-optimal surgical candidate.

paragraphs:[

Brain SRS

Brain SRS — Guideline-based coverage criteria for intracranial metastases and retreatment (consolidated):

SRS is recommended over WBRT to preserve neurocognitive function and quality of life for patients with limited brain metastases (guidelines support SRS alone for up to 4 intact lesions; conditional support for 5–10 lesions in selected patients).

Adults eligible for SRS alone generally have ECOG 0–2 and meet lesion/volume thresholds per guidelines: - Up to 4 intact brain metastases: SRS recommended (strong; high-quality evidence). - 5–10 intact brain metastases: SRS conditionally recommended in selected patients (conditional; low-quality evidence). - Lesion size and dose guidance per trials: single-fraction SRS 20–24 Gy for lesions <3 cm (trial-based dosing: 24 Gy for <2.0 cm, 20 Gy for 2.0–2.9 cm in some RCTs); multifraction options include 27 Gy in 3 fractions or 30 Gy in 5 fractions for larger lesions or cavity treatments.

For resection cavities and postoperative settings, SRS to the surgical cavity is preferred over postoperative WBRT to improve local control while preserving cognition; multi-fraction SRS may be preferred for larger cavities.

Repeat SRS may be considered for new metastatic lesions that have not previously undergone SRS and for selected retreatment of previously SRS-treated lesions, recognizing increased risk of radiation-induced effects; retreatment after prior WBRT may be appropriate in selected patients.

Skull‑base chordoma / chondrosarcoma

Skull-base chordoma and chondrosarcoma — SRS coverage criteria:

SRS may be used as adjuvant, definitive, or salvage therapy for selected skull-base chordomas and chondrosarcomas when ALL of the following are met: - Prior maximal safe resection has been performed when feasible and SRS is used for small residual or recurrent disease. - Residual or target tumor volume is suitable for SRS (evidence supports better local control for residual volume < 20 mL; many series report median volumes in the single-digit cm3 range). - Dose planning permits a marginal dose generally ≥ 15 Gy (single-fraction) for small targets; institutional practice and tumor size may guide fractionation when needed to meet normal tissue constraints. - The multidisciplinary team deems SRS appropriate to deliver high focal dose while sparing adjacent critical structures (e.g., cranial nerves, brainstem, optic apparatus).

notes_on_evidence_and_limits:

Evidence from systematic reviews and multicenter series supports reasonable local control and acceptable adverse event rates for selected patients; most data are retrospective and long-term follow-up varies. Prior radiation is associated with shorter progression-free survival; careful case selection and dosimetry are required.

Craniopharyngioma (FSRT / SRS)

Craniopharyngioma — FSRT / SRS coverage criteria:

FSRT or single-/hypofractionated SRS may be considered for residual or recurrent craniopharyngioma when ALL of the following are met: - SRS/FSRT is used for residual or recurrent disease after surgery or when surgery is contraindicated. - Tumor size and location permit safe delivery of stereotactic doses without exceeding optic apparatus and hypothalamic–pituitary dose constraints. - Multidisciplinary evaluation supports SRS/FSRT to preserve vision and control tumor growth.

evidence_notes:

Systematic reviews and case series demonstrate high tumor control rates and preservation or improvement in visual function in many patients; hypopituitarism and visual risks exist and require endocrine and ophthalmologic monitoring. FSRT (multifraction) is often preferred when OAR constraints limit single-fraction SRS.

Liver SBRT

Liver SBRT — Coverage for HCC and selected intrahepatic cholangiocarcinoma (IHC):

SBRT is covered as definitive, consolidative, or salvage therapy for liver‑confined HCC without regional or distant metastasis and for unresectable intrahepatic cholangiocarcinoma when ALL of the following are met: - The tumor(s) are liver‑confined (no extrahepatic disease) or IHC is locally unresectable and SBRT dose constraints can be met. - Underlying liver function, tumor location, and size permit safe delivery of hypofractionated/high-dose EBRT (selection typically favors Child‑Pugh A or well‑compensated liver disease; individual assessment required). - Multidisciplinary evaluation has considered and exhausted or deemed unsuitable other locoregional options (e.g., resection, ablation, transarterial therapies) or SBRT is chosen as an alternative or after these therapies fail. - Appropriate image-guidance and planning techniques are available and dose fractionation is selected based on tumor size and proximity to organs at risk. Typical practice: 3–5 fraction regimens (e.g., 45–60 Gy in 3 fractions reported in trials) or other regimens selected to maximize local control while respecting normal tissue constraints.

dose_and_outcomes_summary:

Randomized and comparative data suggest SBRT provides high local control and may offer superior local progression‑free survival compared with RFA for small solitary recurrent HCC in selected patients; systematic reviews and phase II trials report high 2–3 year local control rates (often ≥ 90%) with low severe toxicity when patients are carefully selected. For IHC, limited observational data support SBRT as a treatment option for unresectable disease when dose constraints can be met.

Applicable Billing and Procedure Codes

Applicable CPT codes (selected)CPT

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

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Applicable HCPCS/G codesHCPCS

77432	Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session).
77435	Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions.
G0339	Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment.
G0340	Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment.
G0563	Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions.

Procedures and regimens described (no explicit billing codes in this segment)mixed

No codes listed

FDA device product codes referencedmixed

MUJ	FDA product code referenced for SBRT/SRS devices
IYE	FDA product code referenced for SBRT/SRS devices

Applicable Codes - special state noteHCPCS

G0563

HCPCS code noted as not on the State of Louisiana Medicaid Fee Schedule

Lesion and fraction thresholds — quick reference

Brain metastases lesion limitUp to 10 lesions OR cumulative tumor volume <15 cc; all lesions treated in a single SRS session or in 2–5 fractions for SBRT/FSRT

Extracranial oligometastatic lesion limitTotal up to 5 metastatic lesions; each lesion ≤5 cm; all lesions treated concurrently in a single episode

Bone metastasis (non‑spine) fractionationSymptomatic lesions treated in up to five fractions

Spinal palliative fractionation notePalliative spinal treatment using five fractions or less when criteria met (no cord/cauda equina compression)

BMV class cutoffs

Prior Authorization, Documentation, and Operational Notes

Billing Rule

Applicable codes (reference) — inclusion does not imply coverage or reimbursement; providers must follow medical necessity and contractual rules

The following codes are provided for reference only. Inclusion does not imply coverage or reimbursement; providers must document medical necessity and follow federal/state/contractual requirements.

CPT, HCPCS, ICD-10 and other relevant codes may apply — consult plan and state fee schedules
HCPCS G0563: note — not on the State of Louisiana Medicaid Fee Schedule and may not be covered by Louisiana Medicaid

Prior Authorization

Prior authorization: SBRT/SRS indication and dose — requirements to demonstrate indication, performance status, prior RT

Prior authorization is required for most SRS and SBRT requests. Authorization should state the clinical indication, planned dose and fractionation, ECOG/KPS, prior radiation history (including prior doses to the same or adjacent sites), and treatment intent (curative, consolidative, definitive, palliative). For spine cases, include surgical evaluation for stability and presence/absence of cord compression.

Background and Evidence Summary

Stereotactic body radiotherapy (SBRT), also known as stereotactic ablative radiotherapy (SABR), delivers high‑dose external beam radiation to well‑defined extracranial targets in a small number of fractions (commonly ≤5). Treatments use highly conformal planning, immobilization, and image guidance to spare adjacent normal tissues; dose and fractionation vary by tumor site, size, and proximity to organs at risk, with BED considerations (for example, higher BED often correlates with improved local control).

This policy’s coverage positions and exclusions are grounded in randomized trials, systematic reviews, and professional guidelines. Key evidence includes randomized trials comparing SRS alone versus SRS plus WBRT demonstrating cognitive advantages with SRS alone (Brown et al.), guideline recommendations from ASTRO and NCCN on operability assessment for NSCLC and on SBRT dose options for bone metastases, and ASTRO/ISRS guidance for liver and other organ‑specific SBRT indications. These sources inform the policy’s lesion and performance‑status thresholds, recommended dose/fractionation examples, and documentation expectations for prior therapies and multidisciplinary evaluation.

Definitions and Terminology

Definitive Treatment — definition and selection context

Definition — Definitive TreatmentRadiation treatments with curative intent; selection depends on cancer type and stage (NCCN, NCI definitions cited)

Selection contextUsed when no regional or distant metastasis or when unresectable disease meets indication-specific criteria

Relation to policyPolicy lists definitive indications (e.g., HCC, IHC, stage I NSCLC, prostate, selected renal and pancreatic cancers) where definitive intent applies

Oligometastatic Disease (OMD) — definition summary

OMD definition summaryOligometastatic Disease: limited metastatic state (commonly 1–5 lesions) where eradication of all sites could result in long‑term survival; controlled primary tumor optional

Policy lesion limit

Policy Update Changes

2026-02-01material_revisionLatest

Effective 02/01/2026: Added notation that the policy applies to individuals 19 years and older and that SRS/SBRT are covered without further review for individuals younger than 19 years; archived prior version CS180LA.D.

2026-02-01material_revision

Revised extracranial oligometastatic disease criteria: performance-status wording changed to 'KPS score greater than or equal to 70% or ECOG performance status of zero to two' and lesion-count threshold increased from up to three metastatic lesions to up to five metastatic lesions; removed prior specific language limiting palliative spine SBRT to ≤2 fractions without cord/cauda equina compression.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS180LA.E

Change TypeMaterial updates to age applicability, oligometastatic lesion limits, performance status wording, and documentation expectations

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of indication, performance status (KPS ≥70 or ECOG 0–2), prior RT history, and planned SBRT/SRS dose/fractionation.

SourceLink

On This Page

Operational notes: - Good performance status (KPS ≥ 70% or ECOG 0–2), absence of diffuse leptomeningeal disease, controlled extracranial disease or available systemic options, and life expectancy typically ≥ 6 months favor SRS candidacy. - Cumulative treated tumor volume thresholds (e.g., < 15 cc) and total lesion counts (guideline thresholds up to 10 lesions in policy criteria; most evidence supports 1–4 lesions) should be applied in multidisciplinary decision-making.

Coverage: SRS/FSRT is covered when the above guideline-aligned criteria are met; WBRT is not routinely indicated solely to improve overall survival or functional independence after SRS/resection.

Centers delivering liver SBRT should have expertise in liver motion management, image guidance, and an interdisciplinary approach including hepatology and surgical oncology input. SBRT is typically given in 1–9 fractions per ISRS guidance, with 3–5 fractions commonly used in practice.

BMV definitionBrain Metastasis Velocity (BMV) = cumulative number of new brain metastases after first SRS divided by years since initial SRS

BMV class — lowBMV ≤ 3

BMV class — intermediateBMV 4–13

BMV class — highBMV ≥ 14

Total tumor volume for SRS preference

Cumulative volume for SRS preferenceCumulative tumor volume <7 ml favors SRS for 2–4 metastases (preference noted in CNS guidelines)

Lesion count contextSRS recommended for up to 4 intact BMs (ASTRO); extension to higher counts depends on cumulative volume and clinical context

Fractionation implicationSingle‑fraction SRS preferred when cumulative volume small; multifraction FSRT (2–5 fx) for larger volumes

Tumor volume cutoff — skull base chordoma/chondrosarcoma

Skull‑base chordoma/chondrosarcoma SRS volume cutoffResidual tumor volume <20 ml is associated with higher local control and reasonable candidacy for SRS

Dose planning noteMarginal dose often ≥15 Gy in reported series to achieve long-term control

Evidence sourceCase series showed tumor volume <20 ml significantly affected high local control (Hasegawa et al.)

HCC size where SBRT showed particular benefit

HCC size with demonstrated SBRT benefit vs RFASBRT showed superior local progression-free survival versus RFA for recurrent solitary HCC overall, with subgroup benefit for tumors >2 cm (Xi et al.); two‑year LPFS 92.7% (SBRT) vs 75.8% (RFA)

Trial size eligibilityXi et al. included small solitary nodules ≤5 cm in recurrent HCC trial

Liver SBRT typical fractionsRegimens in trials often 3–5 fractions (e.g., 45–60 Gy in 3 fractions reported)

BED thresholds associated with improved control

BED threshold linked to improved controlBED ≥ 100 Gy associated with improved local control and survival in early‑stage NSCLC and favored in guideline remarks

BED10 for optimal local control in oligometastatic NSCLCHigher BED10 (typically >75 Gy) associated with optimal local control per ASTRO/ESTRO guidance

Lower BED contextBED10 in 50–75 Gy range may be acceptable when combined with systemic therapy

Typical SBRT liver dose ranges reported (2 Gy EQD conversions)

Reported EQD2 (2 Gy equivalent) range for liver SBRTStudy-converted equivalent doses ranged approximately 48–114.8 Gy (median ~83.3 Gy) across cohorts and meta-analyses

Typical liver SBRT fractionsFractionation commonly 3–5 fractions for HCC in reported trials (e.g., 45–60 Gy in 3 fractions)

Toxicity contextPooled grade ≥3 hepatic complications ~4.7% and GI grade ≥3 ~3.9% in meta-analysis

Renal SBRT size-based dose regimens

Renal SBRT — small tumors (≤4–5 cm)26 Gy in 1 fraction is an optimal regimen when tumor ≤4–5 cm

Renal SBRT — larger tumors (>4–5 cm)42–48 Gy in 3 fractions recommended for tumors >4–5 cm; alternative 40 Gy in 5 fractions if OAR constraints prevent 3‑fraction regimen

Candidate size guidanceDefinitive renal SBRT candidates generally T1 tumors <7 cm per NCCN

Definitive renal SBRT candidate tumor size (NCCN)

NCCN definitive renal SBRT tumor-size thresholdDefinitive SBRT may be considered for T1 tumors <7 cm in non‑surgical candidates

Anatomic caveatTumors abutting the bowel are considered not amenable to SBRT per NCCN

Standard‑of‑care noteSurgery remains standard for operable RCC; SBRT alternative for inoperable/high‑risk patients

Common SABR dose for stage I SCLC

Common SABR dose for stage I SCLCApproximately 48–54 Gy delivered in 3–5 fractions (median reported ~50 Gy in 4 fractions in database series)

Local control outcomesOne‑year local control ~97.3% for inoperable early‑stage SCLC in pooled analyses

Toxicity profileReported grade ≥3 toxicity rates low in series (pooled grade 3 ~1.4% in meta-analysis)

Durable local control target

Durable local control targetMinimum goal: ≥85% local control at two years (implementation remark in ASTRO/ESTRO guidance)

Performance linkDurable control associated with higher BED10 and appropriate fractionation

Use in planningAim regimens and doses that achieve two‑year LC ≥85% where curative intent or durable control is intended

BED10 associated with optimal local control

BED10 numeric threshold for optimal control> 75 Gy (BED10) associated with optimal local control; BED ≥100 Gy linked to improved outcomes in NSCLC data

Context for lower BED10BED10 of 50–75 Gy may be acceptable when combined with systemic therapy or in selected settings

Clinical implicationSelect fractionation to achieve target BED10 when durable local control is the objective

Document ECOG or KPS, lesion number and size, planned margin dose and fractionation
List prior RT fields, cumulative dose considerations, and normal tissue constraints

Prior Authorization

SRS prior authorization considerations — when prior auth should be requested for brain SRS beyond simple cases

For brain SRS requests beyond straightforward single small-lesion cases, request prior authorization when any of the following apply: multiple metastases (>4), prior WBRT or prior SRS to the same lesion, large lesion size near critical structures, planned staged or repeat SRS, or when multimodality sequencing (surgery + SRS) is being considered. Provide rationale for chosen approach and planned dose/fractionation.

Provide lesion sizes, locations, cumulative doses to nearby OARs, and multidisciplinary input
If selecting SRS over WBRT, reference neurocognitive preservation rationale and applicable trial dosing

Prior Authorization

Prior authorization considerations for SBRT/SABR — acceptable across indications when detailed planning and prior therapies are documented

SBRT/SABR prior authorization should document tumor site and stage, prior local therapies (surgery, ablation, embolization), planned dose and fractionation, intent (definitive, consolidative, palliative), and that dose constraints and IGRT capability can be met. For oligometastatic/consolidative therapy, document number and location of metastases and prior systemic therapy course.

Confirm imaging that establishes oligometastatic limits (commonly ≤5 extracranial metastases per guideline expectations)
Specify image-guidance/IGRT technology and OAR constraints to be used

Prior Authorization

Authorization note for staged/repeat SRS — document planned margin dose and rationale for staged approach in large AVMs

When staged or repeat SRS is proposed (e.g., for large AVMs or residual disease), authorization must include the planned margin dose per stage, interval between stages, cumulative dose rationale, and the clinical justification (tumor/AVM volume reduction strategy, prior hemorrhage history).

Document Spetzler‑Martin grade, nidus volume, prior embolization or surgeries for AVMs
Provide expected number of stages and minimum planned margin dose (e.g., ≥17 Gy cited for staged large AVMs)

Documentation Required

Documentation supports medical necessity — required elements and that records must support medical necessity

Medical records must fully support medical necessity. Lack of sufficient documentation may result in denial. Ensure records include relevant history, physical exam, diagnostic imaging, prior treatments, tumor board or multidisciplinary notes when applicable, and legible documentation available on request.

Medical records must show that clinical criteria are met and support the requested modality and dosing
UnitedHealthcare or delegated reviewers may request records to assess criteria

Documentation Required

Dose and prior RT considerations — prior doses and normal tissue risk must be considered when planning SBRT

Prior RT doses and normal tissue risk must be addressed in authorization requests. Provide prior dose distributions, fields, and dates; calculate estimated cumulative dose to organs at risk and justify the planned SBRT/SRS dose/fractionation relative to prior treatment.

Include prior RT records and dose–volume histograms where available
State how OAR dose constraints will be respected given prior exposure

Note

WBRT evidence affecting authorization — WBRT reduces intracranial relapse but not functional independence/OS; affects authorization choices

When choosing SRS versus WBRT for brain metastases, note that randomized trials show SRS alone preserves cognition and quality of life versus WBRT with no OS benefit, though WBRT reduces intracranial relapse. Authorization may favor SRS for limited brain metastases when appropriate but include salvage strategy if intracranial recurrence risk is high.

If WBRT is being proposed, document rationale given impact on cognition and intracranial control
If SRS chosen, document lesion number/size consistent with ASTRO/NCCN guidance

Prior Authorization

Dose-constraint / IGRT requirement — SBRT appropriate only if dose constraints and IGRT adherence can be demonstrated

SBRT/SRS requests must demonstrate that appropriate dose-constraint planning and image-guided radiation therapy (IGRT) capabilities are available and will be used. Include planned OAR constraints, verification imaging strategy, motion management technique, and physics/quality assurance measures.

Specify IGRT modality (CBCT, fiducials, surface tracking) and motion management (gating, breath-hold)
Attach dose–volume constraints and how they comply with guideline-recommended limits

Prior Authorization

Operability evaluation and trial-preference for SBRT vs surgery — documentation must show inoperability or trial enrollment for operable cases

For stage I NSCLC, document thoracic surgical evaluation and operability assessment. SBRT for operable patients should be limited to clinical trial enrollment or documented high operative risk/refusal after informed surgical consultation.

Include thoracic surgeon consultation notes, cardiopulmonary risk assessment, and reason for nonoperative management if applicable
If enrolled in a trial, provide trial ID and protocol details

Denial Risk

Selection-based denial risk — exclusions include specific malignancy types, pregnancy, diffuse metastases, and anatomic contraindications

Certain scenarios may lead to selection-based denials: hematologic malignancies, primary CNS tumors, diffuse metastatic disease not amenable to focal therapy, pregnancy, or other trial-ineligible presentations noted in pivotal studies. Anatomic contraindications (e.g., lesions abutting bowel for renal or abdominal tumors where constraints cannot be met) may also preclude SBRT.

Provide justification when treating borderline or trial-excluded diagnoses
If anatomy or proximity to OARs precludes safe delivery, note this explicitly — denial risk is higher

Documentation Required

Documentation risks for AVM SRS — higher volume/grade linked to lower obliteration and higher complications; inadequate documentation risks denial

AVM SRS/staged or repeat SRS authorization must include detailed AVM characteristics (Spetzler‑Martin grade, nidus volume), history of hemorrhage, prior embolization or surgery, margin doses used previously, and expected obliteration probability versus risk. Inadequate documentation of volume/grade and prior interventions increases denial risk.

Provide pre- and post-treatment imaging, prior radiosurgery parameters, and justification for repeat or staged approach
State expected margin dose and planned strategies to minimize complications

Note

FDA approval not sufficient for coverage — FDA device approvals are informational and do not guarantee coverage

FDA device approvals are informational only. FDA clearance/approval of an SRS/SBRT device or accessory does not in itself establish coverage. Provide clinical justification and medical necessity irrespective of device status.

Refer to FDA product listings for device details, but include clinical indications and evidence supporting use
Do not rely on FDA approval alone to establish medical necessity

Denial Risk

Documentation requirement risk — medical records required to assess clinical criteria; lack may lead to denial

Insufficient or missing documentation may result in denial. Ensure submitted records fully support clinical criteria, including imaging reports, prior treatment details, performance status, multidisciplinary discussion notes, and planned technical delivery documents (e.g., treatment plan, DVHs).

UnitedHealthcare may request additional records; timely submission avoids processing delays
Documentation must link diagnosis, prior therapies, and rationale for chosen SBRT/SRS regimen

Billing Rule

State fee schedule denial risk — HCPCS G0563 may not be covered by Louisiana Medicaid as it is not on the state fee schedule

Check state fee schedules for billing codes prior to submission. HCPCS G0563 is not listed on the Louisiana Medicaid fee schedule and may not be reimbursed by that program; other state programs may have similar exclusions.

Verify state-specific coverage and fee-schedule inclusion when billing for utilization management or coordination codes

Documentation Required

Expected clinical documentation — required clinical details including performance status, imaging, prior therapies, and multidisciplinary input

Expected clinical documentation to support authorization requests varies by indication but commonly includes: performance status (ECOG/KPS), lesion number/size/location, imaging (CT/MRI/PET) reports, prior local and systemic therapies with dates, surgical evaluations (thoracic/spine/ENT/etc.), and multidisciplinary tumor board notes when available.

For oligometastatic/consolidative therapy: number/location of metastases, prior systemic therapy details, and imaging confirming stability or response
For spine: neurologic exam, stability assessment, and surgical consultation notes

Documentation Required

Renal SBRT technical and follow-up documentation — techniques to spare renal volume and post-treatment surveillance

For renal SBRT, include technical details to minimize irradiated renal parenchyma (e.g., conformal planning, renal-sparing strategies), baseline renal function, laterality/solitary kidney status, and a post-treatment surveillance plan (cross-sectional abdominal imaging every 6 months and chest imaging as appropriate). Avoid routine post-SBRT biopsy unless imaging suggests progression.

Provide baseline creatinine/eGFR and note stage of chronic kidney disease
Describe techniques to reduce intermediate-dose wash and OAR sparing

Prior Authorization

Consideration of conventional RT prior to SBRT — conventional palliative RT options may be appropriate in some settings

Consider conventional palliative RT before selecting SBRT when appropriate (e.g., short expected survival, diffuse symptomatic disease, or when SBRT constraints cannot be met). Prior authorization should explain why SBRT is preferred over conventional RT if SBRT is requested.

Document life expectancy and goals of care when choosing SBRT for palliation
If cEBRT is chosen instead, provide rationale relative to symptom control and logistics

Prior Authorization

Preferred modality sequencing — authorization may favor SRS over WBRT for limited brain metastases when appropriate

Preferred modality sequencing should be documented (for example, SRS preferred over WBRT for limited brain metastases to preserve cognition; SBRT preferred over cEBRT for certain vertebral or pulmonary indications per guideline recommendations). Explain sequencing rationale and salvage options.

If deviating from preferred sequencing, provide multidisciplinary rationale
Reference guideline dose/fractionation when applicable

Prior Authorization

Positioning relative to other local therapies — SBRT appropriate when other curative/local options are not possible

Position SBRT relative to other local therapies in the record: when surgery, ablation, embolization, or transplant are not viable or have failed, document why SBRT is appropriate and why alternative local therapies are not feasible.

Document consultations with relevant specialties and reasons other local therapies are not possible or were unsuccessful
For liver and biliary sites, note prior catheter-based or ablation attempts and current liver function

Prior Authorization

Prior systemic therapy for pancreatic SBRT — SBRT typically recommended following induction/systemic chemotherapy

For pancreatic SBRT, document prior systemic therapy when used (neoadjuvant or induction chemotherapy) and surgical candidacy. SBRT is typically considered after induction/systemic chemotherapy for borderline resectable or locally advanced disease.

Include chemotherapy regimen, cycles, and response imaging if using SBRT as consolidation or definitive locally ablative therapy
If adjuvant SBRT is proposed after resection, note that adjuvant use is generally recommended only in trials/registries

Step Therapy

Step therapy — renal cell carcinoma — surgery remains standard; SBRT alternative for inoperable or decline-of-surgery cases

For renal cell carcinoma, surgery remains the standard of care; SBRT is an option for patients who are medically inoperable, decline surgery, or are high risk. Authorization should document surgical evaluation and reasons for nonoperative management.

Provide tumor size, location, and whether tumor abuts bowel or OARs that preclude SBRT
State recommended SBRT dose regimen based on tumor size per ISRS guidance

Prior Authorization

Clinical sequencing expectation — consolidative local therapy often after initial systemic therapy in suitable patients

Document clinical sequencing expectations: consolidative local therapy is often offered after initial systemic therapy in suitable oligometastatic patients; provide timing (e.g., after 2–3 cycles or months) and imaging showing no progression before local therapy.

For oligometastatic NSCLC, confirm ≤5 extracranial metastases (many trials had 1–2) and that local therapy aims for durable local control
Attach tumor board consensus when available

Note

Place in treatment pathway — SRS front-line option for select AVMs and small deep lesions per evidence; versus other modalities for functional cases

State place in the treatment pathway when requesting SBRT/SRS (definitive, consolidative, palliative, salvage). For tremor or functional indications, document prior medical therapy failure and rationale for ablative radiosurgery; for AVMs, document when SRS is used front-line versus adjunct to embolization or surgery.

Provide prior therapies and why SBRT/SRS is preferred at this point in care
For functional indications (e.g., tremor), document failure of medical therapy and surgical candidacy assessment

Step Therapy

Step considerations vs medical therapy or cEBRT — SRS for medically refractory tremor after medical therapy failure; reflect guideline considerations

When SRS is used after failure of medical therapy (e.g., medically refractory tremor) or when compared to cEBRT, document prior therapy attempts and guideline-based rationale. For spine SBRT, document ECOG/KPS, absence of mechanical instability, and contraindications to surgery per trial eligibility.

Include prior medical therapy history for functional indications and expert justification for radiosurgical approach
For spine indications, provide imaging excluding instability or progressive cord compression

Documentation Required

Technique and sequencing considerations — intraocular tumor planning and device considerations per NCCN

Technique and sequencing considerations: for intraocular, pituitary, and other specialized sites, document planning specifics (fiducials, immobilization, lesion localization), fractionation choices, and follow-up plans aligned with NCCN/ASTRO/ISRS guidance.

For pituitary SRS, include prior surgery details and endocrine follow-up plans given hypopituitarism risk
For intraocular tumors, describe fiducial or localization strategy and multidisciplinary ophthalmic input

Policy applies OMD criteria: total up to 5 metastatic lesions; each lesion ≤5 cm; all lesions treated concurrently

Clinical implementationMultidisciplinary assessment recommended; many trials included mostly 1–2 lesions despite 1–5 definition

Brain Metastasis Velocity (BMV) — definition and stratification

BMV definitionBMV = cumulative number of new brain metastases after first SRS divided by time (years) since the initial SRS

BMV stratificationClasses: ≤3 (low), 4–13 (intermediate), ≥14 (high)

Prognostic relevanceHigher BMV associated with shorter median survival after repeat SRS in cohort analyses

SRS — intracranial stereotactic radiosurgery definition and common regimens

SRS definitionFocal high‑dose radiation delivered to intracranial targets, typically single‑fraction (commonly 16–20 Gy) or a few fractions; FSRT refers to 2–5 fractions

Common intracranial regimensExamples: 16–20 Gy x1; 24–27 Gy in 3 fractions; 30 Gy in 5 fractions per NCCN/ASTRO guidance

Use casesUsed for intact metastases, postoperative cavities, AVMs, and selected benign or functional intracranial conditions

SBRT — definition and typical regimens

SBRT definitionStereotactic body radiotherapy delivers high‑dose, hypofractionated radiation to extracranial targets in ≤5 fractions with high precision

Typical regimens examplesCommon examples include 45–60 Gy in 3 fractions for liver HCC; 1200–1600 cGy x1 (nonspine) or 2400 cGy in 2 fractions (spine) for bone metastases; 3–5 fraction regimens widely used

Clinical rolesUsed for definitive, salvage, and metastasis‑directed therapy depending on tumor site and patient factors

Classic radiation-induced liver disease (RILD)

Classic RILD definitionRadiation‑induced liver disease (RILD) — severe hepatic toxicity after liver irradiation; rare after SBRT with appropriate selection but risk rises with worse baseline liver function

Risk modifiersChild‑Pugh class correlates with grade ≥3 hepatic complications; careful dose constraints and image guidance required

Clinical implicationAssess liver function and OAR constraints before liver SBRT to minimize RILD risk

Peripheral vs central lung tumors — definition and implications

Peripheral vs central lung tumors — definitionPeripheral tumors are located away from central mediastinal structures; central tumors are adjacent to critical mediastinal structures and carry higher toxicity risk

Implication for fractionationCentral tumors often require more fractionation or modified regimens to meet OAR constraints

Clinical cautionUltracentral lesions warrant individualized assessment due to increased toxicity potential

SBRT / Hypofractionation — examples

Hypofractionation examplesExamples include 30 Gy/5 fractions; 33 Gy/5 fractions; 36 Gy/3 fractions; prostate schedules 42.7 Gy/7 or five‑fraction SBRT regimens

RationaleDelivers higher biologic dose in fewer treatments improving convenience and potential tumor control while requiring precise IGRT and planning

Common use casesUsed for primary organ targets (lung, liver, prostate) and oligometastases where OAR constraints allow

SBRT/SABR — term definition and general note

SBRT/SABR term noteStereotactic Body Radiotherapy / Stereotactic Ablative Radiotherapy — high‑dose, hypofractionated external beam radiation with advanced planning and image guidance

Course limitPolicy and coding note: SBRT courses generally do not exceed five fractions

Clinical usesUsed for definitive, salvage, metastasis‑directed, and palliative indications depending on site and patient factors

Oligometastatic disease — typical one-to-five lesion definition

Typical lesion-count definitionOligometastatic disease typically defined as one to five metastatic lesions with all sites safely treatable

Primary control optionalControlled primary tumor is optional in many definitions but often preferred

Trial nuanceMany trials enrolled mostly patients with 1–2 lesions despite 1–5 definition — consider when applying evidence

Durable local control — guideline metric

Durable local control guideline metricMinimum 85% local control at two years specified as a target for durable control

BED relationshipHigher BED10 (typically >75 Gy) associated with achieving this durable control in SBRT-alone approaches

Implementation remarkUse durable LC target in planning definitive/metastasis‑directed regimens

Obliteration — AVM obliteration definition and timing

Obliteration definitionRadiographic demonstration (angiography or MRI) of complete AVM nidus disappearance after SRS, often assessed years after treatment

Assessment timingMean time to obliteration after repeat SRS ~33 months in meta-analysis; actuarial rates reported at 5–10 years in cohort studies

Outcome componentsOptimal obliteration outcome often defined with absence of post‑SRS hemorrhage and no permanently symptomatic radiation‑induced changes

Optimal outcome (AVM SRS)

Optimal AVM SRS outcome definitionAVM obliteration with no post‑SRS hemorrhage and no permanently symptomatic radiation‑induced changes (as used in Ding et al.)

Predictors of optimal outcomeSmaller nidus volume, lower Spetzler‑Martin grade, absence of prior embolization/hemorrhage, and higher margin dose associated with better outcomes

Repeat SRS expectationsRepeat SRS obliteration rate ~60.8% (meta‑analysis) with acceptable complication profile in selected patients

Treatment success (tremor) — definition used in ET studies

Treatment success (tremor) — definitionComplete or near‑complete resolution of tremor or noticeable improvement measured by Fahn‑Tolosa‑Marin (FTM) components; meta-analytic treatment success ~86.6%

Clinical selectionUsed for medically refractory essential tremor when surgery contraindicated or declined

Typical GKRS dosingSingle‑fraction maximum 130–150 Gy with 4‑mm collimator targeting ventral intermediate nucleus in many series

Hypopituitarism (post-SRS) — definition and risk context

Hypopituitarism (post‑SRS) — definitionNew endocrine hormone deficiencies following pituitary SRS; pooled risk estimates ~13.6% (one review) to ~21% (another meta‑analysis)

Monitoring implicationPeriodic endocrine surveillance recommended after pituitary SRS due to risk of new deficits

Dose contextMedian single‑fraction SRS doses ~15 Gy reported in pooled analyses for NFPA

SBRT/SRS dose examples — common regimens

SBRT/SRS dose example — spineSpine SBRT example: 2400 cGy in two fractions frequently cited in guidelines and trials

Nonspine single‑fraction exampleNonspine SBRT single‑fraction examples: 1200–1600 cGy x1 for selected bone metastases

Alternative regimens3–5 fraction regimens commonly used to achieve equivalent BED when OAR constraints require fractionation

SRS — alternate definition reference

Alternate SRS definition noteSRS — high‑precision radiation delivered in single or few fractions for intracranial targets; FSRT denotes 2–5 fractions for larger lesions to improve safety

Clinical preferenceSingle‑fraction SRS used for small lesions; FSRT used for larger cavities or lesions near critical structures

TerminologySRS sometimes used for select extracranial lesions delivered in single high‑dose fractions when anatomy allows

FDA device approvals — product code references

FDA device approvals — informationalFDA device approvals and product codes (e.g., MUJ, IYE) are referenced for information but do not determine coverage

Regulatory referencePolicy cites FDA product code listings as informational only; prior authorization must adhere to payer criteria

Provider actionDevice approval status should not be used alone to justify coverage requests

Oligometastatic Disease (OMD) — updated definition note

Updated OMD definition noteOligometastatic Disease definition updated in policy; commonly one to five lesions and all sites safely treatable (implementation remark)

Policy revision contextRevision replaced prior lesion-count wording from up to three lesions to up to five lesions

ApplicationUse updated OMD definition when assessing consolidative/metastasis‑directed therapy prior authorization

Definitive Treatment — updated definition note

Definitive Treatment — updated definitionDefinitive Treatment: radiation delivered with curative intent; selection depends on tumor type/stage and is used for listed definitive indications (HCC, NSCLC stage I/IIA, prostate, selected renal/pancreas)

Policy applicationDefinitive intent determinations should follow listed criteria (tumor size, node status, operability) in the policy when authorizing treatment

DocumentationAuthorization should document curative intent, staging, and multidisciplinary evaluation where indicated

2026-02-01administrative_update

Expanded medical records/documentation language clarifying that documentation may be required to assess clinical criteria and must fully support medical necessity and be made available upon request.

2026-02-01administrative_update

Updated definitions for 'Definitive Treatment' and 'Oligometastatic Disease (OMD)'.

2026-02-01material_update

Added state-specific coding note that HCPCS code G0563 is not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered by Louisiana Medicaid.