Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (for New Mexico Only)
Defines UnitedHealthcare medical policy for SRS and SBRT services applicable only to New Mexico beneficiaries aged 19 and older, describing covered indications, documentation expectations, and coding references.
Added notation to indicate this policy applies to individuals 19 years of age and older; SRS and SBRT covered without further review for individuals younger than 19 years of age.
Revised list of proven and medically necessary indications for stereotactic radiation therapy, including additions for bone metastasis (non-spine) with criteria, neurologic conditions refractory to treatment, and expanded spinal lesion criteria.
Revised coverage criteria for newly diagnosed brain metastasis to require 'absence of diffuse brain metastases' and modified leptomeningeal and excluded diagnoses.
Revised criteria for individuals undergoing repeat stereotactic radiation therapy for brain metastasis, including change to leptomeningeal language, alteration of extracranial disease assessment, and removal of a 12-month treated-lesion limit.
Added criterion for definitive treatment to include intrahepatic bile duct cancer (cholangiocarcinoma) for unresectable tumors.
Replaced wording around surgical candidacy for non-small cell lung cancer to allow for decision not to pursue surgery after appropriate consultation.
Expanded the allowed total number of metastatic lesions for extracranial oligometastatic disease from up to three to up to five lesions and adjusted performance status phrasing.
Removed language indicating SBRT for palliative treatment of spinal bone metastases is proven and medically necessary when using 2 fractions or less.
Added medical records documentation expectations, including that documentation must fully support medical necessity and may be required for review.
Updated definitions for 'Definitive Treatment' and 'Oligometastatic Disease (OMD)."
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