ALL of the following

• Covered Indications - CNS/Head/Spine

  • Primary central nervous system malignancies, generally used as a boost or salvage therapy for lesions < 5 cm (includes high-grade gliomas).
  • Primary and secondary tumors involving brain or spine parenchyma, meninges/dura, or immediately adjacent bony structures.
  • Benign brain and spinal tumors (e.g., meningiomas, acoustic neuromas, schwannomas, pituitary adenomas, pineocytomas, craniopharyngiomas, glomus tumors, hemangioblastomas).
  • Cranial vascular malformations such as arteriovenous malformations, cavernous malformations, and hemangiomas.
  • Other cranial non-neoplastic conditions such as trigeminal neuralgia and refractory movement disorders.
  • Relapse in a previously irradiated cranial or spinal field where stereotactic precision is required to avoid unacceptable vital tissue radiation.

    Documentation of prior irradiation and clinical necessity required in the medical record.

• Covered Indications - SBRT Specific

  • Stage T1 or T2a non-small cell lung cancer ≤ 5 cm in diameter, no nodal or distant disease, and patient is not a candidate for surgical resection.≤ 5 cm
  • Spinal or vertebral body tumors (metastatic or primary) in patients who have received prior radiation therapy.

    Includes radio-resistant spinal metastases (e.g., renal cell carcinoma, melanoma, sarcoma).

• Coverage Preconditions and Performance Status

  • For metastatic brain or spine lesions: stable systemic disease and reasonable survival expectations.
  • Karnofsky performance status 40 or greater (or expected to return to ≥70 with treatment), or ECOG performance status ≤ 3 (or expected to return to ≤2 with treatment).KPS ≥ 40 or ECOG ≤ 3

    Expectation of improvement with treatment may be required.

• Limitations and Exclusions

  • SRS not covered for treatment of seizures and functional disorders except for trigeminal neuralgia and refractory movement disorders; uveal melanoma is not covered.
  • SBRT not covered for primary or metastatic tumors of the liver, pancreas, kidney, prostate, and adrenal glands.
  • SRS not covered when treatment is for anything other than a severe symptom or serious threat to life/critical functions, or when unlikely to provide functional improvement or meaningful disease stabilization, including patients with widespread metastases and limited life expectancy, or patients with poor performance status (KPS < 40 or ECOG > 3).KPS < 40 or ECOG > 3

• Administrative Requirements

  • Prior authorization is required.

    See submission requirements below.

  • Requests must be submitted via UHA's online portal; contact UHA at 808-532-4000 to establish a login if needed.
  • Requests must include the radiation oncologist's consultation notes.

    Inclusion of codes in provider tables does not guarantee reimbursement; provider contracts and member benefits apply.

• Exceptional Coverage Consideration

  • Patients meeting eligibility and inclusion criteria in the latest NCCN guidelines with recommendation strength 2A or above may be considered for case-by-case coverage despite other limitations; adequate documentation is required.