Stereotactic Radiosurgery and Stereotactic Body Radiotherapy Page 1 of 102 Medical Policy An Independent licensee of the Blue Cross Blue Shield Association Title: Stereotactic Radiosurgery and Stereotactic Body Radiotherapy Professional Institutional Original Effective Date: October 17, 2006 Original Effective Date: May 1, 2007 Revision Date(s): January 20, 2007; Revision Date(s): September 25, 2007; April 1, 2007; September 25, 2007; June 26, 2008; January 1, 2009; June 26, 2008; January 1, 2009; June 30, 2009; February 25, 2011; June 30, 2009; February 25, 2011; January 15, 2013; March 27, 2014; January 15, 2013; March 27, 2014; January 21, 2016; December 20, 2017; January 21, 2016; December 20, 2017; March 27, 2019; January 15, 2021; March 27, 2019; January 15, 2021; March 29, 2021; April 28, 2021; March 29, 2021; April 28, 2021; September 17, 2021 September 17, 2021 Current Effective Date: March 29, 2021 Current Effective Date: March 29, 2021 State and Federal mandates and health plan member contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service. The BCBSKS Medical Policies contained herein are for informational purposes and apply only to members who have health insurance through BCBSKS or who are covered by a self-insured group plan administered by BCBSKS. Medical Policy for FEP members is subject to FEP medical policy which may differ from BCBSKS Medical Policy. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents of Blue Cross and Blue Shield of Kansas and are solely responsible for diagnosis, treatment and medical advice. If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan. Populations Interventions Comparators Outcomes Individuals: Interventions of Comparators of interest Relevant outcomes include: • With non-neoplastic interest are: are: • Overall survival intracranial conditions • Stereotactic • Surgery • Symptoms (eg, arteriovenous radiosurgery • Medical therapy • Treatment-related malformations) morbidity • Quality of life Individuals: Interventions of Comparators of interest Relevant outcomes include: • With non-neoplastic interest are: are: • Overall survival intracranial conditions • Surgery • Symptoms Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Stereotactic Radiosurgery and Stereotactic Body Radiotherapy Page 2 of 102 Populations Interventions Comparators Outcomes (eg, trigeminal neuralgia • Stereotactic • Medical therapy • Treatment-related refractory to medical radiosurgery morbidity management) • Quality of life Individuals: Interventions of Comparators of interest Relevant outcomes include: • With non-neoplastic interest are: are: • Symptoms neurologic disorders • Stereotactic • Surgery • Treatment-related (eg, epilepsy primary or radiosurgery • Medical therapy morbidity secondary tumor- • Quality of life related) Individuals: Interventions of Comparators of interest Relevant outcomes include: • With non-neoplastic interest are: are: • Overall Survival neurologic disorders: • Stereotactic • Surgery • Symptoms mesial temporal epilepsy radiosurgery • Medical therapy • Treatment-related refractory to medical morbidity management • Quality of life Individuals: Interventions of Comparators of interest Relevant outcomes include: • With non-neoplastic interest are: are: • Overall survival neurologic disorders: • Stereotactic • Surgery • Symptoms Treatment- tremor and movement radiosurgery • Medical therapy related morbidity disorders • Quality of life Individuals: Interventions of Comparators of interest Relevant outcomes include: • With non-neoplastic interest are: are: • Overall survival neurologic disorders: • Stereotactic • Surgery • Symptoms (eg, chronic pain) radiosurgery • Medical or surgical • Treatment-related therapy morbidity • Quality of life Individuals: Interventions of Comparators of interest Relevant outcomes include: • With benign neoplastic interest are: are: • Overall survival intracranial lesion(s) (eg, • Stereotactic • Other forms of • Symptoms acoustic neuromas, radiosurgery radiotherapy • Treatment-related pituitary adenoma, • Surgery morbidity nonresectable residual or • Combinations of other • Quality of life recurrent meningiomas) forms of radiotherapy, surgery, or chemotherapy Individuals: Interventions of Comparators of interest Relevant outcomes include: • With benign neoplastic interest are: are: • Overall survival intracranial lesion(s) • Stereotactic • Other forms of • Symptoms (craniopharyngioma, radiosurgery radiotherapy • Treatment-related glomus jugulare tumors) • Surgery morbidity • Combinations of other • Quality of life forms of radiotherapy, surgery, or chemotherapy Individuals: Interventions of Comparators of interest Relevant outcomes include: • With malignant interest are: are: • Overall survival neoplastic intracranial • Stereotactic • Other forms of • Symptoms lesion(s) (eg, gliomas, radiosurgery radiotherapy • Treatment-related astrocytomas) • Surgery morbidity • Combinations of other • Quality of life forms of radiotherapy, surgery, or chemotherapy Individuals: Interventions of Comparators of interest Relevant outcomes include: • With malignant interest are: are: • Overall survival neoplastic intracranial • Stereotactic • Other forms of • Symptoms lesion(s) (eg, brain radiosurgery radiotherapy • Treatment-related metastases) • Surgery morbidity Current Procedural Terminology © American Medical Association. 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Contains Public Information Stereotactic Radiosurgery and Stereotactic Body Radiotherapy Page 3 of 102 Populations Interventions Comparators Outcomes • Combinations of other • Quality of life forms of radiotherapy, surgery, or chemotherapy Individuals: Interventions of Comparators of interest Relevant outcomes include: • With uveal melanoma interest are: are: • Overall survival • Stereotactic • Other forms of • Symptoms radiosurgery radiotherapy • Treatment-related • Surgery morbidity • Combinations of other • Quality of life forms of radiotherapy, surgery, or chemotherapy Individuals: Interventions of Comparators of interest Relevant outcomes include: • With primary and interest are: are: • Overall survival metastatic spinal or • Stereotactic body • Other forms of • Progression-free survival vertebral body tumors radiotherapy radiotherapy • Disease-free survival who have received prior • Surgery • Symptoms spinal radiotherapy • Combinations of other • Treatment-related forms of radiotherapy, morbidity surgery, or • Quality of life chemotherapy Individuals: Interventions of Comparators of interest Relevant outcomes include: • With stage T1 or T2A interest are: are: • Overall survival non-small cell lung • Stereotactic body • Other forms of • Progression-free survival cancer who are not radiotherapy radiotherapy • Disease-free survival candidates for surgical • Surgery • Symptoms resection • Combinations of • Treatment-related radiotherapy, surgery, or morbidity chemotherapy • Quality of life Individuals: Interventions of Comparators of interest Relevant outcomes include: • With primary or interest are: are: • Overall survival metastatic tumor of the • Stereotactic body • Other forms of • Progression-free survival liver that is considered radiotherapy radiotherapy • Disease-free survival inoperable • Surgery • Symptoms • Combinations of other • Treatment-related forms of radiotherapy, morbidity surgery, or • Quality of life chemotherapy Individuals: Interventions of Comparators of interest Relevant outcomes include: • With primary prostate interest are: are: • Overall survival carcinoma • Stereotactic body • Other forms of • Progression-free survival radiotherapy radiotherapy • Disease-free survival • Surgery • Symptoms • Combinations of other • Treatment-related forms of radiotherapy, morbidity surgery, or • Quality of life chemotherapy Individuals: Interventions of Comparators of interest Relevant outcomes include: • With pancreatic interest are: are: • Overall survival adenocarcinoma • Stereotactic body • Other forms of • Progression-free survival radiotherapy radiotherapy • Disease-free survival • Surgery • Symptoms • Combinations of other • Treatment-related forms of radiotherapy, morbidity surgery, or • Quality of life chemotherapy Current Procedural Terminology © American Medical Association. All Rights Reserved. Contains Public Information Stereotactic Radiosurgery and Stereotactic Body Radiotherapy Page 4 of 102 Populations Interventions Comparators Outcomes Individuals: Interventions of Comparators of interest Relevant outcomes include: • With primary or interest are: are: • Overall survival metastatic renal cell • Stereotactic body • Other forms of • Progression-free survival carcinoma who are not radiotherapy radiotherapy • Disease-free survival good surgical candidates • Surgery • Symptoms • Combinations of other • Treatment-related forms of radiotherapy, morbidity surgery, or • Quality of life chemotherapy Individuals: Interventions of Comparators of interest Relevant outcomes include: • With oligometastases interest are: are: • Overall survival involving lung, adrenal • Stereotactic body • Other forms of • Progression-free survival glands, or bone (other radiotherapy