Clinical Policy: Stereotactic Body Radiation Therapy Form

CENTENE
Corporation

Clinical Policy: Stereotactic Body Radiation Therapy
Reference Number: CP.MP.22
Date of Last Revision: 10/24

Coding Implications
Revision Log

See Important Reminder at the end of this policy for important regulatory and legal
information.

Description
Stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) are radiation
therapies delivered via stereotactic guidance to a small, precise target. Both largely spare the
surrounding tissue by converging multiple non-parallel radiation beams into one sharply defined
target, thereby greatly reducing the amount of radiation to which the surrounding tissue is
exposed. SBRT is used to treat extra-cranial sites and can be performed in one to five sessions
(fractions). SRS is used to treat intra-cranial and spinal targets. SRS is typically performed in a
single session but can be performed in a limited number of sessions, up to a maximum of five.
Gamma-ray photons, X-ray photons, protons, helium ions, and neutrons have all been used for
SBRT and SRS.

III.It is the policy of health plans affiliated with Centene Corporation that there is insufficient
evidence to support more than five sessions of SBRT or SRS for indications other than those
listed above.

Background
Stereotactic body radiation therapy or stereotactic ablative therapy (SBRT) and stereotactic
radiosurgery (SRS) both pair a high degree of anatomic-targeting accuracy and reproducibility
with very high doses of extremely precise, externally generated, ionizing radiation to inactivate
or eradicate a defined target(s). The target is defined by high resolution stereotactic imaging.
The procedure involves a multidisciplinary team often consisting of a surgeon, radiation
oncologist, radiologist, medical radiation physicist, dosimetrist, radiation therapist, radiation
therapy nurse and a specialist of the disease site such as a neurologist.²

CENTENE
Corporation

CLINICAL POLICY
Stereotactic Body Radiation Therapy

Stereotactic describes a procedure during which a target lesion is localized relative to a fixed 3-D
reference system, such as a rigid head frame affixed to a patient, fixed bony landmarks, a system
of implanted fiducial markers, or other similar system. This localization procedure allows
physicians to perform image-guided procedures with a high degree of accuracy and precision.²

The risk of developing permanent damage following SRS varies by the location of the lesion in
the brain. Lesions located deep in the gray matter (thalamus, basal ganglia) or brainstem (pons,
midbrain) carry the maximum risk of neurologic complications. Complications are less likely
with lesions in the frontal and temporal lobes. Fractionated radiation therapy is often preferred to
SRS for the treatment of lesions in the deep gray matter or the brainstem.

Technologies that are used to perform SBRT and SRS include Gamma Knife®, LINAC (linear
accelerator), CyberKnife® and proton beam or heavy-charged-particle radiosurgery. To enhance
precision, various devices may incorporate robotics and real time imaging.³

Gamma Knife
Standard gamma knife uses 192 or 201 beams of highly focused gamma rays all aiming at the
target region. The Gamma Knife is ideal for treating small to medium size lesions.¹⁵

Linear accelerator- (LINAC)
LINAC machines deliver high-energy x-rays, also known as photons. It can provide treatment on
larger tumors in a single session or during multiple sessions (fractionated SRT). The principles
of LINAC are identical to GammaKnife.³,¹⁰,¹⁵

CyberKnife
This device combines a mobile LINAC machine with an image guided robotic system that
delivers either a single large dose or fractionated radiation therapy. The overall length of time of
treatment on a CyberKnife is typically longer than with other radiation therapy modalities.³,⁹

Proton Beam
There is limited use of proton beam in North America; however, the number of centers has
dramatically increased in the last several years.¹⁵ Protons are atoms that carry a positive charge.
Compared to the use of photons (x-rays), the energy from protons conforms to the tumor better
and causes less damage to the surrounding tissue. This allows a greater dose of radiation to be
used due to minimizing the effects to normal tissue.²⁹

The National Comprehensive Cancer Network (NCCN) states that SBRT/extremely
hypofractionated image-guided intensity-modulated radiation therapy (IMRT) regimens (6.5 Gy
per fraction or greater) can be considered as an alternative to conventionally fractionated
regimens in the treatment of prostate cancer at clinics with appropriate technology, physics, and
clinical expertise. Longer follow-up and prospective multi-institutional data are required to
evaluate longer-term results, especially because late toxicity theoretically could be worse in
hypofractionated regimens compared to conventional fractionation (1.8 Gy to 2.0 Gy).¹¹ Results
from a study comparing the efficacy of SBRT plus androgen deprivation therapy (ADT) to
fractionated radiotherapy plus ADT in higher risk prostate cancer support recent NCCN
guideline updates, which include SBRT as a non-preferred option for higher risk biological

males. Findings demonstrated no difference in survival between SBRT + ADT and standard of
care external beam radiation therapy + ADT for high-risk prostate cancer.³⁹

The World Health Organization notes the following information regarding Grade I meningiomas:
stereotactic or image guided therapy is recommended when using tight margins or when close to
critical structures.²⁰

A revision to the metastatic spine guideline notes that in selected cases or recurrences after
previous radiation, SBRT is appropriate.²⁰

Definitive radiation therapy, particularly SBRT, is recommended for individuals with early-stage
non-small cell lung cancer (i.e., stage I through II, NO) who are medically inoperable or those
who refuse surgery.²¹

SBRT for the treatment of pancreatic adenocarcinoma should be delivered at an experienced
high-volume center with technology that allows for image-guided radiation therapy or in a
clinical trial.²² Most recent guidelines from NCCN on the principles of radiation therapy note that
data are limited to support radiation therapy recommendations for locally advanced disease. The
guidelines include SBRT as an “option” in select patients with pancreatic adenocarcinoma with
good performance status and locally advanced disease without systemic metastasis. Chemo
radiation or SBRT may also be an option in select patients who are not candidates for
combination therapy, an option in disease progression when SBRT had not been previously
given, and as an option for isolated local recurrence. SBRT should be avoided if direct invasion
of the bowel or stomach is observed on imaging and/or endoscopy.²²

SBRT can be considered in patients with hepatocellular carcinoma, as an alternative to
ablation/embolization techniques or when these therapies have failed or are contraindicated.
SBRT (one to five fractions) is often used for patients with one to three tumors. SBRT could be
considered for larger lesions or more extensive disease, if there is sufficient uninvolved liver and
liver radiation tolerance can be respected. There should be no extrahepatic disease, or it should
be minimal and addressed in a comprehensive management plan (Category 2B
recommendation).²³

There is currently insufficient evidence to recommend SBRT for treatment of head and neck
cancers, however, it might be beneficial for palliation or for older patients. When using SBRT
techniques in reirradiation, selection of patients who do not have circumferential carotid
involvement is advised. The best outcomes are seen in patients with smaller tumors and no skin
involvement.³¹

A systematic review and meta-analysis of 32 retrospective studies published between 1999 and
2019 demonstrated that the effectiveness and safety of stereotactic radiosurgery (SRS) for
brainstem metastases (BSM) was comparable to SRS for non-brainstem brain metastases. Death
related to BSM progression following treatment with SRS was rare and patients often
experienced symptomatic improvement. Based upon the apparent effectiveness and safety of
SRS for BSM in the context of acute morbidity or death from BSM growth, consideration of

SRS on emerging trials of targeted therapy for non-brainstem brain metastases should be
considered.³⁷

The American Academy of Neurology states there is insufficient evidence to make
recommendations regarding the use of gamma knife thalamotomy in the treatment of essential
tremor.²⁴ Per UpToDate, “Gamma knife thalamotomy has not generally been adopted for
essential tremor due to concerns about delayed radiation side effects, including risk of radiation
necrosis and a theoretical risk of secondary tumor formation.”²⁸

Gamma knife stereotactic radiosurgery can offer a less invasive approach for resection of medial
temporal structures in mesial temporal sclerosis (MTS) by allowing increased preservation of
tissue. SRS may be an excellent option for patients unwilling to undergo invasive open surgical
treatment of MTS. Further randomized trials are ongoing to assess the continued efficacy and
outcomes of SRS as a treatment option in patients with MTS.³⁸ Per UpToDate on seizures and
epilepsy in children, “Stereotactic radiosurgery may be helpful for selected cases when the lesion
is located where a conventional surgical approach is technically difficult or excessively risky.”³⁴
More information is needed on long-term outcome before wider application of this procedure.³⁴

American Society of Radiation Oncology (ASTRO), the American Society of Clinical Oncology
(ASCO), and the American Urological Association (AUA)
Per a recent new guideline on hypofractionated radiation therapy for localized prostate cancer
from ASTRO, ASCO, and the AUA, “Based on high-quality evidence, strong consensus was
reached for offering moderate hypofractionation across risk groups to patients choosing external
beam radiation therapy. The task force reached a weaker consensus for ultrahypofractionated
radiation therapy. Extremely hypofractionated radiation therapy, also known as
ultrahypofractionation, SBRT or stereotactic ablative radiation therapy (SABR) may be offered
for low and intermediate risk prostate cancer, but strongly encourages treatment of intermediate-
risk patients on a clinical trial or multi-institutional registry. For high-risk disease, the panel does
not suggest offering ultrahypofractionation outside of a trial or registry.”³⁰ Recommendations for
ultrahypofractionation were graded by the panel as conditional, reflecting the limited base of
current evidence on this approach. The guideline recommends large-scale randomized clinical
trials and stresses the importance of shared decision making between clinicians and patients.³⁰

Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered
trademark of the American Medical Association. All CPT codes and descriptions are copyrighted
2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions are
from the current manuals and those only included herein are not intended to be all-inclusive and are
included for informational purposes only. Codes referenced in this clinical policy are for
informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage.
Providers should reference the most up-to-date sources of professional coding guidance prior to
the submission of claims for reimbursement of covered services.

CENTENE
Corporation

CLINICAL POLICY
Stereotactic Body Radiation Therapy

CENTENE
Corporation

CLINICAL POLICY
Stereotactic Body Radiation Therapy

CENTENE
Corporation

CLINICAL POLICY
Stereotactic Body Radiation Therapy

3. Chen CC, Chapman PH. Stereotactic cranial radiosurgery. UpToDate. www.uptodate.com.
   Updated March 3, 2024. Accessed September 3, 2024.
4. Koyfman SA. General principles of radiation therapy for head and neck cancer. UpToDate.
   www.uptodate.com. Updated October 30, 2023. Accessed September 3, 2024.
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   UpToDate. www.uptodate.com. Updated June 4, 2024. Accessed September 3, 2024.
7. Tuleasca C, Régis J, Sahgal A, et al. Stereotactic radiosurgery for trigeminal neuralgia: a
   systematic review. J Neurosurg. 2018;130(3):733 to 757. doi:10.3171/2017.9.JNS17545
8. Karajannis MA, Marcus KJ. Focal brainstem glioma. UpToDate. www.uptodate.com.
   Updated March 20, 2023. Accessed September 3, 2024.
9. Shih HA. Radiation therapy of pituitary adenomas. UpToDate. www.uptodate.com. Updated
   August 15, 2024. Accessed September 3, 2024.
10. Mitin T. Radiation therapy techniques in cancer treatment. UpToDate. www.uptodate.com.
    Updated March 16, 2023. Accessed September 3, 2024.
11. National Comprehensive Cancer Network®. NCCN Clinical Practice Guidelines in Oncology
    Version 4.2024 Prostate Cancer.
    https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Published September 07,
12. Accessed October 16, 2024.
13. Local Coverage Determination (LCD): Stereotactic radiation therapy: stereotactic
    radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) (L35076). Centers for
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    database/new-search/search.aspx. Published October 01, 2015 (revised April 1, 2020).
    Accessed September 3, 2024.

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CLINICAL POLICY
Stereotactic Body Radiation Therapy

13. Park JK, Vernick DM, Ramakrishna N. Vestibular schwannoma (acoustic neuroma).
    UpToDate. www.uptodate.com. Updated June 11, 2024. Accessed September 3, 2024.
14. Pollock BE, Lunsford LD. A call to define stereotactic radiosurgery. Neurosurgery.
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16. Singer RJ, Ogilvy CS, Rordorf G. Brain arteriovenous malformations. UpToDate.
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17. Synderman C. Chordoma and chondrosarcoma of the skull base. UpToDate.
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18. Owen D, Iqbal F, Pollock BE, et al. Long-term follow-up of stereotactic radiosurgery for
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19. National Comprehensive Cancer Network®. NCCN Clinical Practice Guidelines in Oncology
    Version 5.2023. Non-Small Cell Lung Cancer.
    https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. Published November 11,
20. Accessed October 16, 2024.
21. National Comprehensive Cancer Network®. NCCN Clinical Practice Guidelines in Oncology
    Version 3.2024. Central Nervous System Cancers.
    https://www.nccn.org/professionals/physician_gls/pdf/cns.pdf. Published March 24, 2023.
    Accessed October 16, 2024.
22. Videtic GMM, Donington J, Giuliani M, et al. Stereotactic body radiation therapy for early-
    stage non-small cell lung cancer: executive Summary of an ASTRO evidence-based
    guideline. Pract Radiat Oncol. 2017;7(5):295 to 301. doi:10.1016/j.prro.2017.04.014
23. National Comprehensive Cancer Network®. NCCN Clinical Practice Guidelines in Oncology
    Version 3.2024 Pancreatic Adenocarcinoma.
    https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf. Published June 19,
24. Accessed October 16, 2024.
25. National Comprehensive Cancer Network®. NCCN Clinical Practice Guidelines in Oncology
    Version 3.2024. Hepatocellular Carcinoma.
    https://www.nccn.org/professionals/physician_gls/pdf/hcc.pdf. Published September 14,
26. Accessed October 16, 2024.
27. Zesiewicz TA, Elble RJ, Louis ED, et al. Evidence-based guideline update: treatment of
    essential tremor: report of the Quality Standards subcommittee of the American Academy of
    Neurology. 2011 (Reaffirmed July 2022);77(19):1752 to 1755.
    doi:10.1212/WNL.0b013e318236f0fd
28. Curley SA, Stuart KE, Schwartz JM, Carithers RL, Hunter KU. Localized hepatocellular
    carcinoma: Liver-directed therapies for nonsurgical candidates not eligible for local thermal
    ablation. UpToDate. www.uptodate.com. Updated December 06, 2022. Accessed September
    3, 2024.
29. Caivano D, Valeriani M, Russo I, et al. Stereotactic body radiation therapy in primary and
    metastatic liver disease. Anticancer Res. 2017 Dec;37(12):7005 to 7010.
30. Su TS, Liang P, Liang J, et al. Long-term survival of stereotactic ablative
    radiotherapy versus liver resection for small hepatocellular carcinoma. Int J Radiat Oncol
    Biol Phys. 2017 Jul 1;98(3):639 to 646.

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CLINICAL POLICY
Stereotactic Body Radiation Therapy

28. Chou KL. Surgical treatment of essential tremor. UpToDate. www.uptodate.com. Updated
    August 15, 2023. Accessed September 3, 2024.
29. DiBiase SJ, Roach M. External beam radiation therapy for localized prostate cancer.
    UpToDate. www.uptodate.com. Updated October 05, 2023. Accessed September 3, 2024.
30. Morgan SC, Hoffman K, Loblaw DA, et al. Hypofractionated radiation therapy for localized
    prostate cancer: executive summary of an ASTRO, ASCO, and AUA evidence-based
    guideline. Pract Radiat Oncol. 2018;8(6):354 to 360. doi:10.1016/j.prro.2018.08.002
31. National Comprehensive Cancer Network®. NCCN Clinical Practice Guidelines in Oncology
    Version 4.2024. Head and Neck Cancers.
    https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf. Published October
    09, 2023. Accessed October 16, 2024.
32. Ryan DP, Mamon H. Initial chemotherapy and radiation for nonmetastatic, locally advanced,
    unresectable and borderline resectable, exocrine pancreatic cancer. UpToDate.
    www.uptodate.com. Updated March 1, 2024. Accessed September 3, 2024.
33. Zelefsky MJ, Kollmeier M, McBride S, et al. Five-year outcomes of a phase 1 dose-
    escalation study using stereotactic body radiosurgery for patients with low-risk and
    intermediate-risk prostate cancer. Int J Radiat Oncol Biol Phys. 2019;104(1):42 to 49.
    doi:10.1016/j.ijrobp.2018.12.045
34. Wilfong A. Seizures and epilepsy in children: refractory seizures. UpToDate.
    www.uptodate.com. Updated April 4, 2024. Accessed September 3, 2024.
35. Health Technology Assessment. Stereotactic Radiosurgery for Trigeminal Neuralgia. Hayes.
    www.hayesinc.com. Published September 26, 2019 (annual review October 20, 2022).
    Accessed December 05, 2023.
36. Shih HA. Overview of the treatment of brain metastases. UpToDate. www.uptodate.com.
    Updated November 23, 2023. Accessed September 3, 2024.
37. Chen WC, Baal UH, Baal JD, et al. Efficacy and Safety of Stereotactic Radiosurgery for
    Brainstem Metastases: A Systematic Review and Meta-analysis. JAMA Oncol.
    2021;7(7):1033 to 1040. doi:10.1001/jamaoncol.2021.1262
38. Chang EF, Englot DJ, Vadera S. Minimally invasive surgical approaches for temporal lobe
    epilepsy. Epilepsy Behav. 2015;47:24 to 33. doi:10.1016/j.yebeh.2015.04.033
    39.

CLINICAL POLICY Stereotactic Body Radiation Therapy

https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/ASTRO-SRS_ModelPolicy.pdf Published June 2022. Accessed September 3, 2024.

44. Gondi V, Bauman G, Bradfield L, et al. Radiation Therapy for Brain Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol. 2022;12(4):265 to 282. doi:10.1016/j.prro.2022.02.003
45. National Institute for Health and Care Excellence. Stereotactic radiosurgery for trigeminal neuralgia: interventional procedures guidance [IPG715]. https://www.nice.org.uk/guidance/ipg715/chapter/2-The-condition-current-treatments-and-procedure. Published February 02, 2022. Accessed September 3, 2024.
46. American Society for Radiation Oncology (ASTRO). Model Policy: Stereotactic Radiosurgery (SRS). https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/ASTRO-SRS_ModelPolicy.pdf. Updated June 2020. Accessed October 16, 2024.

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