Radiation Therapy: (SBRT) Stereotactic Body Radiation Therapy/ (SRS) Stereotactic Radiosurgery; Brain Metastasis

POLICY INITIATED: 06/30/2019 MOST RECENT REVIEW: 06/30/2019 POLICY # HH-5139

Overview Statement The purpose of these clinical guidelines is to assist healthcare professionals in selecting the medical service that may be appropriate and supported by evidence to improve patient outcomes. These clinical guidelines neither preempt clinical judgment of trained professionals nor advise anyone on how to practice medicine. The healthcare professionals are responsible for all clinical decisions based on their assessment. These clinical guidelines do not provide authorization, certification, explanation of benefits, or guarantee of payment, nor do they substitute for, or constitute, medical advice. Federal and State law, as well as member benefit contract language, including definitions and specific contract provisions/exclusions, take precedence over clinical guidelines and must be considered first when determining eligibility for coverage. All final determinations on coverage and payment are the responsibility of the health plan. Nothing contained within this document can be interpreted to mean otherwise. Medical information is constantly evolving, and HealthHelp reserves the right to review and update these clinical guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from HealthHelp. All trademarks, product names, logos, and brand names are the property of their respective owners and are used for purposes of information/illustration only.

Associated Procedure Codes: Procedure Code Description Code Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), 32701 (photon or particle beam), entire course of treatment Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple 61796 cranial lesion Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 61798 complex cranial lesion Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal 63620 lesion

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Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of 77371 treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of 77372 treatment of cranial lesion(s) consisting of 1 session; linear accelerator based Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more 77373 lesions, including image guidance, entire course not to exceed 5 fractions Image guided robotic linear accelerator-based stereotactic radiosurgery, complete G0339 course of therapy in one session, or first session of fractionated treatment Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, G0340 per session, second through fifth sessions, maximum five sessions per course of treatment

Definition:

1. SBRT (Stereotactic Body Radiation Therapy) is a method of external beam radiotherapy (EBRT) that accurately delivers a high dose of irradiation in one or few treatment fractions to

an extracranial target.14

2. Stereotactic radiosurgery (SRS) is a non-surgical radiation therapy used to treat functional abnormalities and small tumors of the brain. It can deliver precisely-targeted radiation in

fewer high-dose treatments than traditional therapy, which can help preserve healthy tissue.

Guideline: Delivery of radiation therapy utilizing SBRT (Stereotactic Body Radiation Therapy) or SRS (Stereotactic Radiosurgery) for the central nervous system (CNS) may be medically appropriate and supported by evidence to improve patient outcomes for the following indication. . Radiation therapy utilizing SBRT for brain metastasis from any primary site may be reasonable and appropriate for a patient who has 4 brain metastases or less when the patient’s medical record demonstrates the following: o Treatment to be delivered consists of 1 fraction 2, 7, 9 where the patient has four (4) metastatic lesions to the brain or less 7, 8, 9; and EITHER of the following:

• This is for definitive/curative therapy; 8

• Patient has received radiation to this site previously1, 8 o Treatment to be delivered consists of 1 fraction 2, 9 where the patient has four (4) metastatic lesions to the brain or less 7 , Eastern Cooperative Oncology Group ECOG Performance Status Grade of less than or equal to one (1) OR a KPS Grade of greater than or equal to eighty (80) 1, 7 and EITHER of the following:

• This is treatment for an isolated local recurrence;8

• The treatment is for a recurrent tumor 8 o Treatment to be delivered consists of 1 fraction for palliative care where the patient has four (4) metastatic lesions to the brain 7, 8 or less and tumor is causing symptoms.9 o The patient has five (5) metastatic lesions to the brain or less; o Treatment to be delivered consists of 1 fraction 7,9 and EITHER of the following: • This is being requested as a boost for the initial course of treatment; 8, 9

• There is no active disease except for this area of local recurrence 9

References 1. AIM Clinical Guidelines, Radiation Oncology. Effective date March 9, 2019 2. NCCN Clinical Practice Guidelines in Oncology: Central Nervous System Cancers V1.2019, National Comprehensive Cancer Network., https://www.nccn.org/professionals/physician_gls/pdf/cns.pdf 3. Singh, R., Davis, J., & Sharma, S. (2016). Stereotactic Radiosurgery for Trigeminal Neuralgia: A Retrospective Multi-Institutional Examination of Treatment Outcomes. 4. Alahmadi, H., Zadeh, G., Laperriere, N., Vachhrajani, S., Mazloom, N., Gentili, F., & Hodaie, M. (2012). Trigeminal nerve integrated dose and pain outcome after gamma knife radiosurgery for trigeminal neuralgia. Journal of radiosurgery and SBRT, 1(4), 295-301. 5. Wang, C., Sun, W., Kirkpatrick, J., Chang, Z., & Yin, F. (2018). Assessment of concurrent stereotactic radiosurgery and bevacizumab treatment of recurrent malignant gliomas using multi-modality MRI imaging and radiomics analysis. Journal of Radiosurgery and SBRT, 5(3), 171-181. 6. Fogh, S. E., Andrews, D. W., Glass, J., Curran, W., Glass, C., Champ, C. ... & Comber, E. (2010). Hypofractionated stereotactic radiation therapy: an effective therapy for recurrent high-grade gliomas. Journal of clinical oncology, 28(18), 3048. 7. Extended Survival and Prognostic Factors for Patients with ALK-Rearranged Non–Small-Cell Lung Cancer and Brain Metastasis 8. Kimberly L. Johung, Norman Yeh, Neil B. Desai, Terence M. Williams, Tim Lautenschlaeger, Nils D. Arvold, Matthew S. Ning, Albert Attia, Christine M. Lovly, Sarah Goldberg, Kathryn Beal, James B. Yu, Brian D. Kavanagh, Veronica L. Chiang, D. Ross Camidge, and Joseph N. Contessa, Journal of Clinical Oncology 2016 34:2, 123-129 9. Stereotactic Radiosurgery for Treatment of Brain Metastases Shahed N. Badiyan, William F. Regine, Minesh Mehta. Journal of Oncology Practice 2016 12:8, 703-712 10. Cranial Stereotactic Radiosurgery: Current Status of the Initial Paradigm Shifter Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, and Jay S. Loeffler, Journal of Clinical Oncology 2014 32:26, 2836-2846 11. Lee, A., Chao, S., & Murphy, E. Acoustic neuroma. www.appliedradaitononcology.com February 2013. 12. Rogers, L., Barani, I., Chamberlain, M., Kaley, T. J., McDermott, M., Raizer, J. ... & Vogelbaum, M. A. (2015). Meningiomas: knowledge base, treatment outcomes, and uncertainties. A RANO review. 13. Conti, A., Pontoriero, A., Arpa, D., Siragusa, C., Tomasello, C., Romanelli, P. ... & Tomasello, F. (2012). Efficacy and toxicity of Cyber Knife re-irradiation and “dose dense” temozolomide for recurrent gliomas. Acta neurochirurgica, 154(2), 203-209. 14. Stannard, C., Sauerwein, W., Maree, G., & Lecuona, K. (2012). Radiotherapy for ocular tumours. Eye (London, England), 27(2), 119–127. doi:10.1038/eye.2012.241Guckenberger, M., Andratschke, N., Alheit, H., Holy, R., Moustakis, C., Nestle, U. … Deutschen Gesellschaft für Radioonkologie (DEGRO) (2014). Definition of stereotactic body radiotherapy: principles and practice for the treatment of stage I non-small cell lung cancer. Strahlentherapie und Onkologie: Organ der Deutschen Rontgengesellschaft ... [et al], 190(1), 26–33. doi:10.1007/s00066- 013-0450- 15. Rajendran, R. (2019, May 28). Stereotactic Radiosurgery and Stereotactic Body Radiotherapy (SBRT). Retrieved from https://www.radiologyinfo.org/en/info.cfm?pg=stereotactic