Stereotactic Body Radiation Therapy Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 10|01|2025 POLICY LAST REVIEWED: 07|16|2025

OVERVIEW Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) are 3-dimensional conformal radiotherapy methods that deliver highly focused, convergent radiotherapy beams on a target that is defined with 3-dimensional imaging techniques with ability to spare adjacent radiosensitive structures. SRS primarily refers to such radiotherapy applied to intracranial lesions and SBRT refers to therapy sometimes applied to intracranial as well as other areas of the body. This policy is applicable to SBRT only; SRS is a covered service.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION
Not applicable

POLICY STATEMENT Effective 10/1/2025, Stereotactic Body Radiation Therapy (SBRT) is covered for both Medicare Advantage Plans and Commercial Products.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for the applicable radiation therapy benefits/coverage.

BACKGROUND Not applicable

CODING Medicare Advantage Plans and Commercial Products
The following CPT code(s) are covered for Medicare Advantage Plans and Commercial Products and prior authorization is not required:

Two to Five (2-5) Fractions:
Cranial SBRT-Stereotactic body radiation therapy Note: This code is used for cranial although the code description is not specific to cranial
77435 Stereotactic body radiation therapy, treatment management, per treatment course, to one or

        more lesions, including image guidance, entire course not to exceed 5 fractions

One to Five (1-5) Fractions:
Spinal SBRT Stereotactic body therapy
32701 Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or

       particle beam), entire course of treatment

77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions,

       including image guidance, entire course not to exceed 5 fractions

77435 Stereotactic body radiation therapy, treatment management, per treatment course, to one or

      more lesions, including image guidance, entire course not to exceed 5 fractions

RELATED POLICIES Medical Coverage Policy | Stereotactic Body Radiation Therapy

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Non-Reimbursable Health Service Codes

PUBLISHED Provider Update, September 2025 Provider Update, April 2025 Provider Update, December 2024 Provider Update, October 2023 Provider Update, November 2022

REFERENCES Not applicable

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS