UnitedHealthcare SRS/SBRT Prior Auth Policy Update

Coverage Criteria for SRS and SBRT

Covered indications and criteria

Covered when ALL of the following are met for each listed indication (grouped by indication):

Primary covered indications: Acoustic neuroma (vestibular schwannoma); chordoma and chondrosarcoma; craniopharyngioma; glomus jugulare tumors; hemangiomas of the brain; intracranial AVMs; meningioma; pineal gland tumors; pituitary adenoma; recurrent gliomas; to treat a previously irradiated field; trigeminal neuralgia refractory to medical therapy; uveal melanoma

Listed as proven and medically necessary indications.

Brain metastasis - newly diagnosed: Individual has a good performance status (KPS ≥70 or ECOG 0-2) AND absence of leptomeningeal metastases AND no diagnosis of lymphoma, germ cell tumor, or small cell carcinoma AND has up to 10 lesions OR cumulative tumor volume <15 cc AND all lesions treated in single session for SRS or 2–5 fractions for SBRTlesions ≤10 or cumulative tumor volume <15 cc

From Coverage Rationale for newly diagnosed brain metastasis.

Brain metastasis - repeat stereotactic radiation: Individual has good performance status (KPS ≥70 or ECOG 0-2) AND absence of leptomeningeal metastases AND stable extracranial disease on restaging within past 2 months AND life expectancy >6 months AND total number of brain metastases treated in past 12 months ≤13 AND all lesions treated in single session for SRS or 2–5 fractions for SBRT≤13 lesions treated in past 12 months

Repeat treatment criteria.

Brain metastasis - re-treatment after WBRT: Re-treatment after previous whole brain radiation therapy is listed as an indication.

Listed without additional detailed criteria in this excerpt.

Definitive NSCLC: Stage I or IIA with negative mediastinal lymph nodes AND tumor size ≤5 cm AND individual is medically inoperable or refuses surgery after thoracic surgery evaluationtumor size ≤5 cm

Definitive treatment indication.

Definitive renal cancer: Stage I renal cancer AND individual is a non-optimal surgical candidate

Definitive treatment indication for renal cancer.

Definitive HCC, pancreatic adenocarcinoma, and prostate cancer: Hepatocellular carcinoma without regional or distant metastasis; pancreatic adenocarcinoma without distant metastasis; prostate cancer without distant metastasis (each listed as definitive treatment indications).

Listed as covered definitive indications.

Extracranial oligometastatic disease: Primary tumor among colorectal, melanoma, NSCLC, prostate, renal, or sarcoma AND controlled primary tumor (≥3 months since definitive treatment with no progression) AND performance status KPS ≥70 or ECOG 0-2 AND life expectancy ≥6 months AND total up to three metastatic lesions (including previously treated lesions) AND each lesion ≤5 cm AND no malignant pleural effusion/leptomeningeal/peritoneal carcinomatosis AND all metastatic lesions treated concurrently in a single episode of care AND SBRT completed in 5 fractions for entire course regardless of number of lesions treated≤3 lesions; each lesion ≤5 cm; SBRT ≤5 fractions

Specific concurrent treatment and fractionation requirement.

Palliative spinal bone metastases SBRT: Using 2 fractions or less AND individual has no spinal cord compression or cauda equina compression≤2 fractions

Palliative coverage criteria.

Brain Metastases — Coverage logic

Coverage considerations for SRS in brain metastases

Limited intact brain metastases (preferred SRS): SRS is strongly recommended for patients with ECOG 0-2 and up to four intact brain metastases; single-fraction SRS (20-24 Gy) is recommended for lesions <2 cm; alternative multifraction options include 27 Gy in 3 fractions or 30 Gy in 5 fractions.ECOG 0-2; ≤4 intact BMs

ASTRO and NCCN recommendations

Postoperative/Resected cavity: SRS is strongly recommended to improve local control in patients with resected brain metastases and is preferred over WBRT to preserve neurocognitive function when limited additional brain metastases exist.postoperative cavity

NCCN and ASTRO guidance

When WBRT may be considered: WBRT reduces intracranial relapse rates compared with observation or SRS alone and may be considered when intracranial control is prioritized over cognitive preservation, or when multiple/diffuse metastases exist.

Chordoma and Chondrosarcoma — Coverage logic

Coverage considerations for SRS in skull-base chordoma and chondrosarcoma

Adjunctive or salvage SRS for skull-base chordoma: SRS may be covered as adjunctive or salvage therapy for primary or recurrent skull-base chordomas and chondrosarcomas to achieve local control, especially after maximal safe resection; evidence is primarily retrospective with variable follow-up.small-to-medium volume lesions; prior surgery common

Systematic review of 714 individuals reports ~55% no progression at latest follow-up and ~12% overall adverse events

Skull base chordoma and chondrosarcoma

SRS/SBRT for skull base chordoma and chondrosarcoma is supported when used as primary or adjunctive therapy in selected patients with small to medium tumors where high dose with normal tissue sparing is required.

Skull base chordoma/chondrosarcoma SRS candidacy: Indicated for residual or newly diagnosed small to medium skull base chondrosarcomas and chordomas as primary or adjunctive treatment, particularly after maximal safe resection or when surgery is not feasible; tumor size/volume and prior radiation affect outcomestumor volume small to medium (examples: median volumes reported 1–50 mL; marginal doses ~15–16 Gy in series)

Multimodal management often required; prior radiation associated with shorter PFS

Craniopharyngioma (residual or recurrent)

SRS/FSRT for craniopharyngioma is an option for residual or recurrent disease, balancing tumor control with preservation of vision and pituitary function.

Craniopharyngioma SRS/FSRT candidacy: Indicated for residual or recurrent craniopharyngioma after surgery; fractionated stereotactic RT or radiosurgery achieves high tumor control rates and may improve visual outcomes; tumor volume and complete radiosurgical coverage predict better controlmedian margin doses reported ~11.5–13 Gy (GKS) and FSRT series show 3-year PFS ~98% in pooled analyses

Dose reduction may decrease response but reduce visual and pituitary toxicity

Hepatocellular carcinoma (definitive, liver-confined)

SBRT for hepatocellular carcinoma (HCC) confined to the liver is a recommended option for unresectable disease, as an alternative to ablation/embolization, or after failure/contraindication of those therapies.

HCC SBRT candidacy: Indicated for liver-confined, unresectable HCC or when ablation/embolization are contraindicated or unsuccessful; typical regimens 1–9 fractions (commonly 3–5) with reported high local control (2–3 year LC 83–97%) and low rates of severe toxicity with appropriate selectiontumor size typically <3 cm favorable but SBRT used for tumors ≥3 cm; baseline liver function (Child-Pugh) must be assessed due to correlation with hepatic toxicity

ASTRO/ISRS/NCCN support use; no single optimal fractionation established

Non-small cell lung cancer (stage I)

SABR/SRT for early-stage NSCLC is an alternative to surgery in inoperable patients or those refusing surgery and achieves superior local control vs conventionally fractionated radiotherapy.

NSCLC SABR candidacy: Indicated for stage I (peripherally located) NSCLC in medically inoperable patients or those who refuse surgery; may be considered in operable patients in select trials; achieves improved local control (HR 0.32 vs standard RT) with acceptable toxicity; fractionation schemes adjusted for tumor location and proximity to critical structurescommon fractionation examples depending on risk and location

Patient performance status and pulmonary function influence outcomes

NSCLC - Indications and operability

Covered when evidence and guideline-based conditions are met for each disease site

NSCLC - medically inoperable or high operative risk: SBRT is supported for stage I (and selected node-negative stage IIA) NSCLC in patients who are medically inoperable; for operable patients with standard operative risk, surgery is preferred and SBRT is not recommended as an alternative outside of a clinical trial; for high operative risk or refuse surgery after thoracic surgical evaluation SBRT may be reasonable.stage I or selected node-negative stage IIA

ASTRO and NCCN guidance

Pancreatic adenocarcinoma - Indications

Covered when disease is nonmetastatic and clinical context aligns with published evidence

Pancreatic adenocarcinoma - locally advanced or borderline resectable: SBRT may be covered for locally advanced pancreatic cancer (LAPC) and borderline resectable pancreatic cancer (BRPC) without distant metastasis, often after induction chemotherapy and with intent of local control or facilitating margin-negative resection; evidence shows improved 2-year OS in pooled studies and lower acute grade 3/4 toxicity compared with CFRT.no evidence of distant metastasis

Many studies use 30 Gy in 5 fractions or fractionated regimens; surgical candidacy and timing relative to chemotherapy should be documented.

Prostate cancer — definitive SBRT/ultra-hypofractionation

Covered when ALL of the following are met (evidence basis summarized):

Prostate SBRT coverage criteria: 1) Localized prostate cancer without distant metastasis; 2) Treatment delivered in a practice with appropriate technology, physics, and clinical expertise; 3) Dose and fractionation consistent with regimens supported by randomized trials or guideline recommendations (examples: 42.7 Gy in 7 fractions or other SBRT schedules); 4) Documentation of risk group, performance status, and shared decision-making regarding androgen deprivation and fractionation approach.

Supported by meta-analysis and randomized trial and guideline endorsements

Primary renal cell carcinoma — definitive SABR

Covered when ALL of the following are met (evidence and guideline-based):

Renal SABR coverage criteria: 1) Biopsy-confirmed primary renal cell carcinoma or multidisciplinary determination of diagnosis; 2) Patient is not a surgical candidate or declines surgery; 3) Tumor is T1–T2a and single lesion meeting size criteria (ISRS: ≤4–5 cm for single-fraction 26 Gy; >4–5 cm consider 42–48 Gy in 3 fractions or 40 Gy in 5 fractions if OAR constraints not met); 4) Tumor not abutting bowel and OAR constraints can be met; 5) ECOG/PS and renal function adequate (e.g., eGFR ≥30 mL/min/1.73 m² in FASTRACK II eligibility).size-based dose selection per ISRS

Supported by FASTRACK II trial and ISRS/NCCN guidance

Extracranial oligometastatic disease — metastasis-directed SABR

Covered when ALL of the following are met (trial-supported):

Oligometastatic SABR criteria: 1) Controlled primary tumor or stable systemic control as defined in trial protocols; 2) Limited number of metastases (typically 1–5 lesions); 3) Intent to treat all sites of disease with ablative SBRT; 4) Patient selection consistent with trials demonstrating OS/PFS benefit (e.g., SABR-COMET, Gomez, Iyengar); 5) Treatment planning meets OAR constraints and institutional expertise is available.commonly 1–5 lesions

Evidence includes randomized and phase II trials showing OS/PFS benefit in selected patients

Pancreatic adenocarcinoma — investigational/limited evidence

Covered only in limited/experimental contexts or clinical trials based on current evidence:

Pancreatic SRS criteria: 1) Locally advanced pancreatic adenocarcinoma without distant metastasis; 2) Consideration for SRS in clinical trial or specialized center setting given small phase I data (15 participants) suggesting feasibility at 25 Gy for local control without grade ≥3 acute GI toxicity; 3) Detailed informed consent regarding limited evidence and potential toxicities.

Single small trial supports feasibility but evidence is limited

Oligometastatic NSCLC and pulmonary oligometastases — guidance-based coverage considerations

Covered when clinical selection and treatment meet guideline recommendations and multidisciplinary consensus

Patient selection: Patient has up to five distant metastases (most trial data involve 1–2 lesions; consider this in decision-making)<=5 lesions

ASTRO/ESTRO strong recommendation; most prospective evidence in 1–2 lesions

Treatment modality and intent: Definitive local therapy (SBRT preferred) or minimally invasive surgery recommended to minimize morbidityDurable local control targets to be achieved

Use doses/fractionations expected to achieve durable local control (minimum 85% at 2 years); higher BED10 (>75 Gy) preferred when SBRT alone is used

Dose/fractionation considerations: Higher BED10 (>75 Gy) with SBRT alone associated with optimal local control; lower BED10 (50–75 Gy) may be acceptable in combination with systemic therapy

Glomus jugulare tumors — SRS coverage considerations

Covered when SRS is used as primary or adjuvant therapy with expected high tumor control and acceptable morbidity

Expected outcomes: High aggregate tumor control (~95%) and symptomatic improvement (~47%) reported in systematic reviews; SRS considered viable alternative to resectiontumor control ~95%

Document expected control and prior treatments

Prior therapies: Account for prior resection or external beam radiotherapy as they impact toxicity and outcomesdocument prior resection/RT

Several series include previously operated or irradiated patients

Cavernous sinus and orbital hemangiomas — SRS coverage considerations

Covered when SRS is indicated for symptomatic lesions or when surgery is high risk

Efficacy: SRS produced tumor regression in all reported series with symptomatic improvement in majorityimaging-confirmed regression common

Median margin doses reported ~12.6–14.5 Gy with optic nerve doses <9 Gy in some series

Safety: Low rates of delayed tumor growth, cranial neuropathy, or hypopituitarism reported in series with medium-term follow-upfollow-up median ~40–80 months

Document cranial nerve function baseline and follow-up

Intracranial AVMs — coverage considerations for SRS and staged/repeat procedures

Covered when AVM characteristics and prior treatments match scenarios with documented benefit and acceptable risk

Optimal outcome definition: AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changesas defined in Ding et al 2017

Used as a composite favorable outcome

Predictors of better outcome: Smaller nidus volume, lack of prior hemorrhage, absence of prior embolization, absence of associated aneurysms, and higher margin dose associated with higher obliteration/optimal outcomesmaller volume; higher margin dose (eg ~20 Gy)

Multiple series report margin doses ~18–20 Gy and correlate with obliteration rates

Repeat or staged SRS: Repeat SRS increases eventual obliteration rates; staged volumetric SRS may be used for large lesions unsuitable for surgery but often requires multiple procedures and margin dose >=17 Gy for reasonable chance of benefit

Evidence-based considerations for SRS by diagnosis

Coverage considerations informed by published evidence and society guidelines; SRS may be considered when clinical and radiographic criteria appropriate for the lesion type are met.

AVMs - candidate considerations: SRS may be considered for AVMs not amenable to surgery; prospective volume-staged SRS can benefit large AVMs but often requires multiple procedures; minimum margin dose of ~17 Gy or greater associated with higher obliteration rates depending on AVM location.minimum margin dose >= 17 Gy (suggested by series)

Obliteration rates improve with higher margin dose; hemorrhage risk decreases after obliteration but is not eliminated.

Meningiomas: SRS (single-fraction typical prescription 12-16 Gy) provides high local control for benign intracranial meningiomas, especially small-to-medium cranial base lesions; larger volume, prior surgery, margin dose <13 Gy associated with increased progression risk.margin dose < 13 Gy associated with higher progression

10-year local control in reviews ranged 71-100%; toxicity generally low.

Palliative SBRT for painful spinal metastasis

Covered when ALL of the following are met for painful spinal metastasis (evidence-based preference for SBRT over conventional RT in selected patients):

Spine SBRT eligibility: MRI-confirmed painful spinal metastasis involving no more than three consecutive vertebral segments; pain score ≥2 on Brief Pain Inventory; ECOG performance status 0-2; Spinal Instability Neoplasia Score <12; not eligible for initial surgical decompression or surgery deemed unnecessary after surgical evaluationas stated

Based on Sahgal et al. trial inclusion criteria and ASTRO guideline

Prior treatments and evaluation: Assessment of prior RT doses, normal tissue risk, prognosis, and patient goals documented prior to SBRT selectionas stated

Implementation remark in ASTRO guidance

Recommended SBRT regimens: Examples supported: 24 Gy in 2 fractions for spine; non-spine SBRT 12-16 Gy single fraction (1,200–1,600 cGy) per ASTRO summary

Salvage SRS/FSRT for recurrent gliomas

Coverage stance for recurrent high-grade gliomas (SRS/CKR/FSRT) — evidence supports use as salvage therapy in selected patients:

Recurrent malignant glioma salvage SRS: SRS/CyberKnife/LINAC-based SRS or FSRT may be reasonable as salvage therapy for recurrent WHO grade III/IV gliomas, particularly for patients with small volume recurrence, good performance status, and when combined with chemotherapy shows survival trend improvementclinical selection criteria (small volume, KPS>=80, interval from prior RT)

Supported by systematic review and multiple case series showing median OS after reirradiation ~8-11 months and low complication rates

Re-irradiation considerations: Patient selection should consider cumulative normalized total dose, interval from prior radiotherapy, lesion size, and predicted risk of radionecrosis; higher prescription doses associated with improved survival in some seriesas per cited studies

Maranzano, Imber, Gigliotti case series findings

Pituitary adenoma (GKRS)

Pituitary adenoma — SRS (Gamma Knife) outcomes summary:

Secretory pituitary adenomas: GKRS may be used as primary or salvage treatment for secretory pituitary adenomas with reported high rates of tumor volume decrease or stability and variable rates of hormonal normalization dependent on subtypefollow-up and tailoring to tumor location/morphometry

Wan et al. series: tumor control rates and hormone normalization percentages by subtype

SRS for trigeminal neuralgia refractory to medical therapy

Trigeminal neuralgia secondary to benign tumors — SRS for symptom control:

Trigeminal neuralgia secondary to tumor: SRS targeting tumor and/or nerve can provide pain relief (BNI I in ~50% and BNI I-IIIb in ~84% in pooled studies), but targeting both tumor and nerve may increase complications such as facial numbness; outcomes and complication rates vary by modality (GKS, LINAC, CKR)as reported ranges

Systematic reviews report varied outcomes and complication rates

SRS/FSRT for uveal melanoma

Uveal melanoma — SRS/FSRT is an effective option for local control and eye preservation in selected tumors:

Uveal melanoma SRS/FSRT: GKRS and CyberKnife/linac-based SRS/FSRT achieve high local control (~96% pooled) and tumor regression with favorable 5-year OS and enucleation-free survival in series; higher doses (≥45 Gy in 3 fractions) associated with better control for large tumors while limiting maximum eye and lens dose (eye ≤50 Gy, lens ≤15 Gy suggested) may improve eye retentiondose and organ-at-risk limits (eye <=50 Gy, lens <=15 Gy suggested)

Meta-analyses and multicenter series support efficacy and dose–OAR trade-offs

Palliative bone metastases: recommended regimens and selection criteria

ASTRO guidance relevant to coverage decisions for palliative radiation to bone metastases:

Conventional palliative RT recommended endpoints: For symptomatic spine bone metastases, RT is recommended to improve ambulatory status, sphincter function, and reduce pain; evaluate spine stability and surgical options before initiating RT.

strength of recommendation: strong; quality of evidence: high

Conventional palliative RT fractionations: Acceptable conventional regimens: 800 cGy x1 OR 1,600 cGy x2 OR 2,000 cGy x5 OR 3,000 cGy x10 for spine metastases when surgery not performed.

strength of recommendation: strong; quality of evidence: high

SBRT fractionations for symptomatic bone metastases: SBRT regimens: non-spine 1,200–1,600 cGy x1 OR spine 2,400 cGy x2.

strength of recommendation: strong; quality of evidence: moderate

Oligoprogression — defined as progression of a limited number of metastatic lesions in the setting of otherwise widespread disease — is explicitly not considered oligometastatic disease for the purposes of this policy. Coverage pathways and trial evidence that support metastasis-directed SBRT/SRS for oligometastatic disease assume controlled or limited systemic disease (e.g., up to 3 lesions or other indication-specific thresholds) and do not apply to scenarios where progression reflects generalized treatment failure.

No additional exclusionary coverage statements are explicitly provided in the excerpted portion of this document.

Observational series in skull-base chordoma/chondrosarcoma and other intracranial tumors show that larger gross tumor volumes and greater maximum tumor diameters are associated with poorer local control after stereotactic treatments. Tumor volume and maximum diameter therefore influence candidacy for single‑session SRS and expected outcomes, and very large lesions are less appropriate for SRS alone given higher progression and retreatment rates.

ASTRO guidance states that for standard operative risk stage I NSCLC patients, SBRT is not recommended as an alternative to lobectomy outside of a clinical trial. Evaluation by a thoracic surgeon within a multidisciplinary team is recommended to determine operability before considering SBRT.

Per NCCN guidance, tumors that are abutting the bowel should be considered not amenable to definitive SBRT and are excluded from candidacy for SBRT when anatomic proximity to bowel prevents meeting organ‑at‑risk constraints.

Randomized trials and pooled analyses of intensive surveillance after curative resection for colorectal cancer found no consistent overall survival benefit (pooled HR ~0.98) despite earlier detection of recurrence. Therefore, intensifying surveillance alone without effective therapeutic options should not be expected to improve OS.

Higher‑grade meningiomas (WHO grade II and III) have substantially lower control rates after single‑fraction SRS compared with benign (grade I) tumors. Series report markedly reduced tumor control for grade II/III lesions, indicating that SRS alone is generally less effective as definitive therapy for higher‑grade meningiomas and should be used with caution or as part of multimodality management.

Patients with neurologically symptomatic spinal cord or cauda equina compression who require immediate surgical decompression were excluded from randomized SBRT trials (for example, the Sahgal et al. spine SBRT trial). When initial surgical decompression is indicated, surgery should be performed prior to consideration of SBRT.

FDA device approvals are provided for informational purposes in this policy; however, FDA approval alone is not a basis for coverage. Coverage determinations require that medical necessity criteria and clinical evidence be met.

Requests that do not meet the policy's explicit clinical criteria — for example, when lesion counts or sizes exceed stated thresholds, performance status is inadequate, or required staging/primary‑control criteria are not met — may be considered not medically necessary and may be denied.

Randomized trials comparing WBRT plus SRS versus SRS alone for patients with one to four brain metastases did not demonstrate an overall survival benefit for adding WBRT, although WBRT reduced intracranial relapse rates and decreased the need for salvage therapies. This supports routinely preferring SRS alone to preserve cognition when appropriate, reserving WBRT for cases where intracranial control is prioritized.

SBRT should not replace proven curative therapies when standard, guideline‑recommended curative options (for example, surgical resection or established ablative therapies) are available and appropriate. The policy does not support substituting SBRT for standard curative treatments outside of accepted trial contexts.

The policy reiterates that use of SBRT in place of lobectomy for patients with operable stage I NSCLC who are standard operative risk is not supported outside clinical trials, consistent with ASTRO recommendations.

More intensive postoperative surveillance after colorectal cancer resection has not been shown to improve overall survival in randomized trials; therefore, increased monitoring alone should not be relied upon to extend survival without effective intervention.

Evidence indicates single‑fraction SRS provides high control for benign meningiomas but that control rates are substantially lower for WHO grade II and III meningiomas. As a result, SRS alone is generally not recommended as definitive monotherapy for higher‑grade meningiomas.

When surgical decompression for spinal cord or cauda equina compression is indicated, SBRT is not the preferred first‑line therapy. Trials of spine SBRT excluded patients requiring immediate surgery; guideline implementation explicitly calls for surgical evaluation before selecting radiotherapy.

Procedure Codes, Dose Thresholds, and Key Numeric Criteria

Applicable procedure codesmixed

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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FDA device product codes (informational)mixed

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

inv-46: Maximum lesion size for certain indications — each lesion ≤ 5 cm (for several indications).

Maximum lesion diameterEach lesion ≤ 5 cm for listed indications (e.g., definitive NSCLC, oligometastatic disease)

ApplicabilityApplies to extracranial oligometastatic disease and definitive NSCLC per coverage criteria

Concurrent treatment requirementAll metastatic lesions must be treated concurrently in a single episode of care when indicated

inv-47: Cumulative brain tumor volume for newly diagnosed brain metastasis — < 15 cc.

Cumulative brain tumor volumeLess than 15 cc for newly diagnosed brain metastasis

Alternate lesion-based limitOr up to 10 lesions if volume criteria not used

Fractionation requirementAll lesions must be treated in single session for SRS or 2–5 fractions for SBRT

inv-48: SRS single-fraction dose for <2 cm intact BM — 2000-2400 cGy (20-24 Gy single fraction).

Recommended single-fraction SRS dose (<2 cm intact BM)2,000–2,400 cGy (20–24 Gy single fraction)

IndicationFor intact brain metastases < 2 cm in diameter in patients with ECOG 0–2

Treatment intentUsed to maximize local control while preserving cognition compared with WBRT when limited BMs

inv-49: Common SRS fractionation schedules — 16-20 Gy x1; 24-27 Gy in 3 fractions; 30 Gy in 5 fractions.

Common SRS fractionation schedules16–20 Gy ×1; 24–27 Gy in 3 fractions; 30 Gy in 5 fractions

Guideline sourceListed as common dose–fractionation options in NCCN and ASTRO guidance

Use considerationsChoice depends on lesion size, location, and proximity to critical structures

inv-50: Tumor size considerations for HCC outcomes.

HCC tumor size and outcomesPatients with HCC < 3 cm have favorable local control after SBRT; SBRT remains effective for tumors ≥ 3 cm though outcomes vary by size

FractionationSBRT commonly delivered in 3–5 fractions (studies report 45–60 Gy in 3 fractions among trials)

Liver function considerationBaseline liver function (Child‑Pugh) correlates with hepatic toxicity risk and influences candidacy

inv-51: Craniopharyngioma tumor volume — median volumes ~1.0 to 5.5 mL.

Reported median tumor volumesSeries report median craniopharyngioma volumes ~1.0 to 5.5 mL

Volume predicts successSmaller tumor volume and complete radiosurgical coverage predict better Gamma Knife SRS outcomes

Typical margin dosesMedian prescription/margin doses in series reported ~11.5–13 Gy (GKS) with variable maximal doses

inv-52: Renal tumor size thresholds for SBRT dose selection.

Renal tumor size thresholds≤ 4–5 cm: single‑fraction 26 Gy; > 4–5 cm: 42–48 Gy in 3 fractions (or 40 Gy in 5 fractions if OAR constraints unmet)

Indication contextSBRT/SABR considered for primary renal cell carcinoma in medically inoperable or surgery‑declining patients

Follow-up and renal functionSurveillance imaging and renal function monitoring recommended post‑SBRT

inv-53: Prostate ultra-hypofractionation regimen example — 42.7 Gy in seven fractions.

Example ultra‑hypofractionation regimen42.7 Gy in seven fractions

Evidence baseSupported by randomized ultrahypofractionation trials and meta-analyses for localized prostate cancer

Program requirementsShould be delivered in practices with appropriate technology, physics, and clinical expertise

inv-54: Max number of distant metastases for recommended definitive local therapy (oligometastatic NSCLC) — up to 5.

Maximum distant metastases for definitive local therapyUp to 5 distant metastases for recommending definitive local therapy in oligometastatic NSCLC

Typical trial populationsMost prospective trials enrolled patients with 1–2 lesions; consider this in decision‑making

Treatment intentAim to treat all sites with ablative therapy (SBRT preferred) to minimize morbidity

inv-55: Durable local control threshold — minimum 85% local control at 2 years.

Durable local control definitionMinimum 85% local control at 2 years (ASTRO/ESTRO implementation remark)

Use in planningDose and fractionation should aim to meet this durable local control benchmark when treating oligometastatic disease

Evidence contextApplied as an implementation target in guideline recommendations for definitive local therapy

inv-56: Higher BED10 associated with optimal local control — > 75 Gy.

BED10 threshold for optimal local control> 75 Gy (BED10) associated with optimal local control when using SBRT alone

Lower BED10 contextBED10 between 50–75 Gy may be acceptable when combined with systemic therapy

Implementation remarkUse higher BED10 dosing where safe to improve durable local control in oligometastatic NSCLC

inv-57: Tumor/AVM volume thresholds (examples).

AVM median volumes reportedExamples include median target volumes ~9.5–11.5 cm3 in staged SRS series

Meningioma median volumesMulticenter series report median meningioma volumes ~4.8–7.3 cm3

Adverse outcome thresholdLesion volume ≥ 10 mL associated with higher rates of complications and lower obliteration/control rates

Background, Definitions, and Evidence Context

Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT/SABR) are high‑precision modalities that deliver large, conformal doses to well‑defined targets. SBRT/SABR is typically delivered to extracranial sites in ≤ 5 fractions, while SRS usually denotes a single‑session high dose to intracranial lesions; FSRT refers to fractionated stereotactic regimens delivered in 2–5 fractions. This policy applies to stereotactic cranial and extracranial radiation procedures and defines covered indications, eligibility thresholds, and documentation expectations for use.

inv-96: SBRT / SABR definition — extracranial target in five fractions or less.

SBRT / SABR definitionExternal beam radiation to an extracranial target delivered in five fractions or fewer with high accuracy and high dose per fraction

Distinguishing noteAlso termed stereotactic ablative radiotherapy (SABR); aims to minimize dose to adjacent normal tissue

Fraction limitTypical SBRT course does not exceed 5 fractions

inv-97: SRS / FSRT definition — single-session high dose vs fractionated stereotactic radiotherapy.

SRS / FSRT definitionSRS: high‑precision, typically single‑session high dose to intracranial lesions; FSRT: fractionated stereotactic radiotherapy delivered in 2–5 sessions

Clinical rationaleFSRT used for larger targets to improve safety by allowing normal tissue repair between fractions

Typical usesSRS for intracranial tumors and select extracranial lesions when single high dose is appropriate

inv-98: Oligometastatic Disease definition under this policy (up to three metastatic lesions).

Oligometastatic disease per policyDefined as up to three metastatic lesions under this policy (policy-specific definition)

Distinction vs oligoprogressionOligoprogression is not considered oligometastatic disease under this policy

Clinical implicationCertain coverage criteria and fractionation requirements apply for oligometastatic indications

inv-99: Brain metastasis velocity (BMV) definition and categories.

BMV definitionBrain metastasis velocity (BMV) = cumulative number of new brain metastases after first SRS divided by time (years) since initial SRS

BMV categoriesLow ≤3; Intermediate 4–13; High ≥14 new metastases per year

Prognostic useBMV associated with overall survival and need for salvage WBRT after DBF

inv-100: SBRT/SABR term synonym note.

Term synonymSBRT and SABR are synonymous terms for high‑dose extracranial stereotactic radiotherapy

Usage noteBoth terms used interchangeably in guidelines and literature

Fractionation contextDelivered in five fractions or fewer

inv-101: SRS/GKS definition note.

SRS/GKS definition noteStereotactic radiosurgery (including Gamma Knife) is high‑precision, typically single‑session radiotherapy for intracranial lesions

FSRT relationWhen fractionation is used for larger intracranial lesions, term FSRT (2–5 fractions) applies

Typical indicationsCraniopharyngioma, pituitary adenoma, small skull‑base tumors among common intracranial SRS uses

inv-102: SBRT/SABR/SRT/HypoFXSRT terminology grouping.

Grouped terminologySBRT/SABR/SRT/HypoFXSRT refer to high‑dose, focal radiotherapy delivered in few fractions (examples across trials)

ExamplesUsed variably across extracranial indications (lung, liver, pancreas) with regimen differences by site

Clinical implicationChoice of term reflects fractionation and site‑specific practice patterns

inv-103: Oligometastatic disease (trial definitions commonly 1–5 lesions).

Common trial definitionsMany trials define oligometastatic disease as 1–5 lesions; trial enrollment often limited to 1–3 lesions for some studies

Policy vs trialsPolicy uses up to 3 lesions for oligometastatic definition but recognizes trial definitions commonly 1–5

Decision-makingConsider both policy limits and trial inclusion criteria when evaluating candidates

inv-104: Ultra-hypofractionation / prostate SBRT example.

Prostate SBRT exampleUltra‑hypofractionation example: 42.7 Gy in seven fractions

Evidence supportSupported by randomized trials showing non‑inferiority to conventional fractionation

Program requirementsDelivered in centers with appropriate expertise and technology

inv-105: Durable local control definition (>=85% at 2 years).

Durable local control definition (guideline)Defined as ≥85% local control at 2 years (ASTRO/ESTRO remark)

Use in planningTarget for dose/fractionation selection when aiming for definitive local therapy

Quality benchmarkApplied as minimum implementation benchmark in oligometastatic NSCLC guidance

inv-106: Higher BED10 definition and threshold (>75 Gy).

Higher BED10 definitionBiologically effective dose with alpha/beta=10 (BED10)

Threshold associated with optimal control> 75 Gy BED10 preferred for SBRT alone in oligometastatic NSCLC

Lower BED10 contextBED10 50–75 Gy may be acceptable when combined with systemic therapy

inv-107: Obliteration (AVM) definition.

Obliteration (AVM) definitionComplete angiographic disappearance of an AVM after SRS (obliteration rates reported vary by staging, dose, and follow‑up)

Outcome componentsFavorable outcome defined as obliteration without post‑SRS hemorrhage or permanently symptomatic radiation effects

TimecourseObliteration often occurs over years and may require staged/repeat SRS; annual hemorrhage risk persists until obliteration

inv-108: Local control (tumors) definition.

Local control (tumors) definitionStability or decrease in tumor volume on imaging after SRS indicating local control

Time horizonsReported control rates vary by tumor type and follow‑up duration (e.g., 5‑year and 10‑year rates cited in series)

Clinical relevanceUsed as primary efficacy endpoint across intracranial stereotactic indications

inv-109: SBRT for spine metastasis examples (24 Gy x2 etc.).

Spine SBRT examplesExamples include 24 Gy in 2 fractions for spine; other regimens studied include single‑fraction 24 Gy

Nonspine SBRTNonspine SBRT dose examples: 1,200–1,600 cGy ×1 per ASTRO recommendations

Eligibility noteUse in patients without spinal cord/cauda equina compression and after surgical consideration per guideline

inv-110: Palliative conventional RT fractionation examples.

Palliative conventional RT examples800 cGy ×1; 1,600 cGy ×2; 2,000 cGy ×5; or 3,000 cGy ×10 for spine when using conventional palliative RT

ContextRecommended when surgery not performed and before selecting SBRT evaluate spinal stability

Guideline sourceASTRO palliative radiation guideline

inv-111: SBRT dose examples for symptomatic bone metastases.

SBRT dose examples for symptomatic bone metastasesNonspine: 1,200–1,600 cGy ×1; Spine: 2,400 cGy ×2 (ASTRO recommendations)

Trial evidenceSahgal et al. trial used 24 Gy in 2 fractions showing superior complete pain response vs cEBRT

Patient selectionConsider ECOG 0–2, absence of neurologic symptoms, and no planned surgical intervention when preferring SBRT

OpenPayer

Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery

Coverage Criteria for SRS and SBRT

Procedure Codes, Dose Thresholds, and Key Numeric Criteria

Authorization, Documentation, and Operational Guidance

Background, Definitions, and Evidence Context