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Home , Radiation therapy

Stereotactic and Stereotactic Body

Policy Number: Original Effective Date: MM.05.008 05/12/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 04/01/2014 Section: Place(s) of Service: Outpatient

I. Description Stereotactic radiosurgery (SRS) is a method of delivering high doses of precisely targeted to intracranial lesions. SRS, when used extracranially, is called stereotactic body radiation therapy (SBRT). The technique differs from conventional radiotherapy, which involves exposing large areas of tissue to relatively broad fields of radiation over a longer duration of sessions. SRS and SBRT entails delivering highly focused convergent beams, sparing adjacent structures. It may offer a non-invasive alternative to invasive , particularly for patients unable to undergo surgery or for lesions that are difficult to access surgically or are adjacent to vital organs. Traditional external beam radiation therapy may involve daily treatments for a duration of 6 weeks or longer. The emerging trend in recent years has been toward shorter, more “hypofractionated” courses, such as with SRS and SBRT. Both SRS and SBRT may be completed with one session (single- fraction) or less may require additional sessions (typically no more than 5) over a course of days, referred to as fractionated stereotactic radiotherapy. Fractionation has been made possible by the ability to duplicate the treatment plan from one session to the next. Fractionation of stereotactic radiotherapy aims to optimize the therapeutic ratio; that is the ratio between tumor control and late effects on normal tissues. The main advantage of fractionation is that is allows higher total doses to be delivered to the tumor because of increased tolerance of the surrounding healthy tissues to each individual, fractionated dose. In addition, some lesions such as large arteriovenous malformations may require more than one procedure to complete the obliteration process. The main methods of this technology include gamma-ray radiosurgery (Gamma Knife), most frequently used for intracranial lesions, and linear-accelerator radiosurgery or LINAC (e.g., ). The radiosurgical procedure using SRS or SBRT is preceded by a process of localizing the target with 3-dimensional imaging such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT).

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II. Criteria/Guidelines

A. SRS utilizing a gamma-ray or linear-accelerator unit is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the following indications: 1. Arteriovenous malformations 2. Acoustic neuromas 3. Pituitary 4. Non-resectable, residual, or recurrent 5. 6. Glomus jugulare tumors 7. Solitary or multiple brain metastases in patients having good performance status and no active systemic disease (defined as extracranial disease that is stable or in remission) 8. Primary of the (CNS), including but not limited to, high-grade (initial treatment or treatment of recurrence) 9. Nasopharyngeal, oropharyngeal and high hypopharyngeal malignancies, spinal cord and meninges 10. Patients with disabling symptoms from Parkinson's disease refractory to conventional 11. refractory to medical management B. SBRT is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the following indications: 1. Patients with stage T1 or T2a non-small (not larger than 5cm) showing no nodal or distant disease and who are not candidates for surgical resection 2. Spinal or vertebral body tumors (metastatic or primary) in patients who have received prior radiation therapy 3. Spinal or vertebral metastases that are radioresistant (e.g., renal cell , and ) 4. Clinically localized cancer ( Stage

IV. Administrative Guidelines A. Precertification is required. To precertify, please complete HMSA's Precertification Request and mail or fax the form as indicated. Requests must include the 's consultation notes. B. Applicable codes:

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CPT Codes Description 61796 Stereotactic radiosurgery (, or linear accelerator), 1 simple cranial lesion 61797 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 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 each additional spinal lesion (list separately in addition to code for primary procedure) 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based 77372 linear accelerator based 77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions 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

HCPCS Description Codes G0173 Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session

V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice . Nothing in this Medical Policy is Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 4

intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating .

Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii's Patients' Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4), generally accepted standards of medical practice and review of medical literature and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA's determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in of any supporting documentation.

VI. References 1. The American College of Radiology (ACR) and the American Society for Radiation (ASTRO). Practice Guideline for the Performance of Stereotactic Radiosurgery. Revised 2011 2. The American College of Radiology (ACR) and the American Society for Radiation Oncology (ASTRO). Practice Guideline for the Performance of Stereotactic Body Radiotherapy. Revised 2009 3. Blue Cross Blue Shield Association. Medical Policy Reference Manual. Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy. Policy #6.01.10. September 2013 4. Chang SD, Adler JR Jr. Treatment of Cranial Base Meningiomas with Linear Accelerator Radiosurgery. 1997 Nov; 41(5):1019-1025. 5. Corn BW, Curran WJ Jr., Shrieve DC, Loeffler JS. Stereotactic Radiosurgery and Radiotherapy: New Developments and New Directions. Semin Oncol 1997 Dec; 24(6):707-714. 6. ECRI Institute. HTAIS hotline service. Cyberknife and Gamma Knife Radiosurgery for Trigeminal Neuralgia. Updated 05/03/07. 7. Kim YS, Kondziolka D, Flickinger JC, Lunsford LD. Stereotactic Radiosurgery for Patients with Non Small Cell Lung Carcinoma Metastatic to the Brain. Cancer 1997 Dec 1; 80(11):2075-83. 8. Kocher M, Voges J, Staar S, et. al. Linear Accelerator Radiosurgery for Recurrent Tumors of the Skull Base. Am J of Clin Oncology 1998 Feb; 21(1):18-22. 9. Miller RC, Foote RL, Coffey RJ, Gorman DA, et. al. The Role of Stereotactic Radiosurgery in the Treatment Of Malignant Skull Base Tumors. Int J Radiat Oncol Biol Phys 1997 Dec 1; 39 (5):977- 981. 10. Motti ED, Losa M, Pieralli S, Zecchineli A, et. al. Stereotactic Radiosurgery of Pituitary Adenomas. Metabolism 1996. Aug; 45 (8 Suppl 1):111-114. 11. Niranjan A, et al. Radiosurgery Techniques and Current Devices. Prog Neurol Surg , 2007; 20:50- 67. 12. Noridian LCD for Stereotactic radiosurgery L33492. Original Effective Date 09/16/2013. Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 5

13. Noridian LCD for Stereotactic body radiation therapy L33490. Original Effective Date 09/16/2013 14. Perez CA, Brady LW, eds, Principles and Practices of Radiation Oncology, 3rd ed, Philadelphia, Lippincott-Raven, 1998. 15. Sasaki T, Kurita H, Saito I, et. al. Arteriovenous Malformations in the Basal Ganglia and Thalamus: Management and Results in 101 Cases. J of Neurosurgery 1998 Feb; 88(2):285-92. 16. Technology Evaluation Center. BCBSA Special report: SRS for Intracranial Lesions by Gamma Beam, Linear Accelerator and Beam Methods. 1999. 17. National Comprehensive Cancer Network. Practice Guidelines in Oncology, Non-Small Cell . Version 2 2013 18. Gruter JP. Kessels AG., et al. Comparison of the Effectiveness of Radiotherapy with , and - for Non-Small Cell Lung Cancer. A meta-analysis. Radiother Oncol 2009 Sept. 3( published ahead of print) 19. Chen et al.: Stereotactic Body Radiation Therapy (SBRT) for Clinically Localized : the Georgetown University Experience. Radiation Oncology 2013 8:58. 20. Katz et al.: Stereotactic Body Radiotherapy for Localized Prostate Cancer: Disease Control and Quality of Life at 6 Years. Radiation Oncology 2013 8:118. 21. Aluwini et al. Stereotactic Body Radiotherapy with a Focal Boost to the MRI-Visible Tumor as Monotherapy for Low- and Intermediate-Risk Prostate Cancer: Early Results. Radiation Oncology 2013 22. Oliai C, Lanciano R, Sprandio B, Yang J, Lamond J, Arrigo S, et al. Stereotactic Body Radiation Therapy for the Primary Treatment Of Localized Prostate Cancer. J Radiat Oncol. 2013 March 2(1):63-70. 23. Goyal K, Einstein D, Ibarra RA et al. Stereotactic Body Radiation Therapy for Non resectable Tumors of the Pancreas. J Surg Res 2012; 174(2):319-25. 24. Casamassima F, Livi L, Masciullo S et al. Stereotactic Radiotherapy for Adrenal Gland Metastases: University of Florence Experience. Int J Radiat Oncol Biol Phys 2012; 82(2):919-23