Prior authorization request form Form

Stereotactic Radiosurgery and Proton Beam Therapy

Last Review Date: July 11, 2025 
Number: MG.MM.RA.13mC2v2

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, (“EmblemHealth”) has adopted the herein policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. Skip Overview and go directly to Guideline Overview Stereotactic radiosurgery (SRS) is a highly precise form of radiation therapy initially used to treat tumors and other abnormalities of the brain (intracranial). When used to treat other parts of the body (extracranial), the procedure is referred to as stereotactic body radiotherapy (SBRT).
Fractionated stereotactic radiotherapy is the term utilized when multiple SRS treatments are administered (typically 2– 5). Despite its name, SRS is a non-surgical procedure that delivers precisely targeted radiation at much higher doses than traditional radiation therapy while sparing healthy adjacent tissue. SRS and SBRT technologies

1. Three-dimensional (3D) imaging and localization techniques that determine the exact coordinates of the target within the body.
2. Systems to immobilize and carefully position the patient.
3. Highly focused gamma-ray or x-ray beams that converge on a tumor or abnormality.
4. Image-guided radiation therapy (IGRT), which uses medical imaging to confirm the location of a tumor immediately before, and in some cases during the delivery of radiation to further improve the precision and accuracy of the treatment.
   Radiation modalities for SRS and SBRT:
5. Gamma Knife — for intracranial indications; consists of multiple beams of highly focused gamma rays converging in three dimensions.
6. The treatment involves four phases: placement of a head frame, imaging of the tumor location, computerized dose planning and radiation delivery.
7. Linear accelerator (LINAC) — for either intracranial or extracranial indications; consists of high-energy x-ray photons or electrons that are delivered to the brain or to outside the brain (extracranially) as with SBRT.

The LINAC involves the same four phases of the Gamma Knife, but unlike the Gamma Knife, which remains motionless during the procedure, part of the LINAC, a gantry, rotates around the patient delivering radiation beams from different angles. (Note: The CyberKnife, a LINAC technology, utilizes a robotic arm that moves around the patient under image-guidance) Compared to the Gamma Knife, the LINAC can use a larger x-ray beam, which enables it to treat larger tumors more uniformly. It can also be used for single-session or fractionated radiotherapy using a relocatable frame, an advantage for large tumors or particularly critical locations.

4. Proton beam therapy (PBT) — uses a special machine called a cyclotron or a synchrotron to generate and accelerate protons (atoms that carry a positive charge).
   The protons leave the machine and are steered by magnets toward the tumor; releasing most of their energy when they hit the tumor (delivering no exit dose beyond the tumor boundary, unlike photons). The result is that the radiation dose may conform to the tumor better with less damage occurring to healthy tissue; thus, potentially enabling the administration of larger doses while minimizing unwanted side effects.
   PBT may be considered reasonable in instances where sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of added clinical benefit to the member. Examples include: i. The target volume is in close proximity to ≥ 1 more critical structure and a steep dose gradient outside the target must be achieved to avoid exceeding the tolerance dose to the critical structure(s) ii. A decrease in the amount of dose inhomogeneity in a large treatment volume is required to avoid an excessive dose "hotspot" within the treated volume to lessen the risk of excessive early or late normal tissue toxicity iii. A photon-based technique would increase the probability of clinically meaningful normal tissue toxicity by exceeding an integral dose-based metric associated with toxicity iv. The same (or an immediately adjacent area) has been previously irradiated and the dose distribution within must be sculpted to avoid exceeding the cumulative tolerance dose of nearby normal tissue

   Guideline Note: For Medicare members see Local Coverage Determination (LCD): Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) Commercial and Medicaid members
   I. Single or multiple-session (fractionated) SRS/SRBT, utilizing any FDA-approved Gamma Knife or LINAC technology, is considered medically necessary for any of the following conditions: A. Nonmalignant cranial/spinal/central nervous system (CNS) tumors/lesions

5. Arteriovenous (AV)/cavernous malformations
6. Acoustic neuroma
7. Craniopharyngioma
8. Glomus tumor
9. Hemangioblastoma
10. Meningioma
11. Pineocytoma
12. Pituitary adenoma
13. Schwannomas
14. Spinal tumors — inoperable primary with compression or intractable pain
    B. Malignant primary tumors/lesions

1. Prostate cancer: i. Low-, intermediate-, and high-risk prostate cancer ii. Negative bone scan within the last 6 months, where applicable

2. CNS (includes spinal tumors); initial or recurrence treatment (see Limitations/Exclusions for gliomas)
   Note: Boost treatment may be considered on a case-by-case basis for larger cranial or spinal lesions (such as sarcomas, chondrosarcomas, chordomas and nasopharyngeal or paranasal sinus malignancies) that have been treated initially with external beam radiation therapy or surgery.
3. Uveal melanoma
4. Non-small cell lung cancer (NSCLC) — medically inoperable Stage I or node-negative Stage IIA
5. Malignant primary tumors of the adrenal gland, kidney, liver and pancreas
   Note regarding pancreatic cancer: Stereotactic body radiation therapy (using up to 5 radiation treatment fractions) will be considered on a case-by-case basis for Commercial and Medicaid members, as consistent with eviCore, for: i. Pre-operative (neoadjuvant resectable or borderline resectable) cases following a minimum of 2 cycles of chemotherapy and restaging in which there is no evidence of tumor progression ii. Definitive treatment for medically inoperable or locally advanced cases following a minimum of 2 cycles of chemotherapy and restaging in which there is no evidence of tumor progression, and the disease volume can be entirely encompassed in the radiation treatment volume. iii. Postoperative (adjuvant) cases in which there is residual gross disease or positive microscopic margins that can be entirely encompassed in the radiation treatment volume C. Malignant metastatic tumors/lesions
6. Brain i. Initial treatment is medically necessary when the following conditions are met: • Lesion no > 5 cm • Karnofsky Performance Status (KPS) > 70 • Primary histology is not germ cell, small cell, or lymphoma • Systemic disease is under control or good options for systemic treatment are available • All lesions can be treated in a single treatment plan in a single fraction (for SRS) or up to 5 fractions (for fractionated SRS)
   Note that all lesions present on imaging must be targeted as a single episode of care. If this cannot be accomplished in a maximum of 5 fractions, each fraction must be billed as 3D conformational or intensity modulated radiation therapy (IMRT), depending on the planning, as the definition of SRS is not met. ii. In a member who has received prior SRS, retreatment with SRS is medically necessary when the following conditions are met: • 1–5 new lesions (no > 5 cm) are present with evidence of controlled systemic disease • KPS score > 70 • Primary histology is not germ cell, small cell, or lymphoma • Member has not been treated with > 2 episodes of radiosurgery in past 9 months • All lesions can be treated in a single treatment plan with a single fraction (for SRS) or up to 5 fractions (for fractionated SRS). Note that all lesions present on imaging must be targeted as a single episode of care. If this cannot be accomplished in a maximum of 5 fractions, each fraction must be billed as 3D conformational or IMRT, depending on the planning, as the definition of SRS is not met iii. In a member who has received prior whole-body radiation therapy (WBRT), SRS may be medically necessary if the member’s KPS is > 70, systemic disease is under control, and life expectancy is > 6 months
   iv. Post-operative SRS is considered not medically necessary

2. Member with NSCLC (who will undergo curative treatment of primary tumor) and presents with 1–3 metastases in the synchronous setting
3. Spinal tumors — recurrent metastatic for members who have undergone prior surgery and conventional radiation therapy
4. Member with colorectal cancer (who will undergo curative treatment of primary tumor) and presents with 1–3 metastases in the lung or liver in the synchronous setting and for whom surgical resection is not possible

5. Member presenting with 1–3 adrenal gland, lung, liver or bone metastases in the metachronous setting when all the following criteria are met: i. Histology is NSCLC, colon, breast, sarcoma, renal cell or melanoma ii. Disease free interval of > 1 year from the initial diagnosis iii. Primary tumor received curative therapy and is controlled iv. No prior evidence of metastatic disease (cranial or extracranial)

   D. Tumors of any type arising in areas of overlap with previously irradiated regions (where there is likely to be obvious clinical benefit) E. SRS is medically necessary for any of the following diseases that are refractory to medical treatment and/or invasive neurosurgical treatment

6. Epilepsy
7. Parkinson’s disease
8. Essential tremor
9. Familial tremor classifications with major systemic disease
10. Trigeminal neuralgia Authorization for this class of diseases will only be granted once all standard treatments have proven to be ineffective. Substantiating documentation must accompany request. Discussion with a Medical Director may also be required. Limitations/Exclusions Stereotactic radiosurgery is regarded as investigational and not medically necessary for the following indications:
11. Gliomas (case by case consideration for inoperable malignant gliomas that have received prior radiation treatment)
12. Chronic pain syndromes
13. Extracranial lesions/tumors (other than those depicted above)
14. SBRT for palliation is not considered medically necessary
15. Psychoneurosis

II. Proton beam therapy (PBT)
Note: For Medicare members see NGS LCD: Proton Beam Therapy Commercial and Medicaid members
PBT is considered medically necessary for the curative treatment of any of the following:

1. Chondrosarcomas and chordomas of the skull base; localized and in postoperative setting
2. Primary CNS cancer (excluding IDH wild-type glioblastoma multiforme)
3. Nonmetastatic primary tumors requiring craniospinal irradiation (e.g., medulloblastoma)
4. Primary ocular tumors including uveal Melanomas when preferential compared to brachytherapy
5. Nasopharynx, nasal cavity, paranasal sinuses or other accessory sinuses cancer
6. Hepatocellular cancer (HCC) or intrahepatic cholangiocarcinoma
7. Stage IIA seminoma
8. Malignancies requiring Craniospinal Irradiation (CSI)
9. Individuals with cancer syndromes such as NF-1, Li-Fraumeni, Ataxia Telangiectasia (with deleterious ATM mutations), Hereditary Retinoblastoma, Lynch syndrome, or Hereditary Breast or Ovarian Cancer (with BRCA1/2 mutations)
10. Primary malignant or benign bone tumors
11. Unresected T3, T4, or node positive head and neck cancers
12. Esophageal cancer
13. Thymomas and Thymic Carcinoma
14. Mediastinal lymphomas
15. Thoracic sarcomas
16. Primary malignant pleural mesothelioma
17. Retroperitoneal Sarcoma
18. Individuals with a single kidney or transplanted pelvic kidney with treatment of an adjacent target volume
19. Liver metastases being treated with curative intent (i.e., oligometastases)
20. Leptomeningeal disease

21. Multiple myeloma

    Benign or malignant tumors or hematologic malignancies in children aged 19 years and younger treated with curative intent PBT for the following indications will be reviewed on a case-by-case basis:

22. Breast Cancer
23. Extrahepatic cholangiocarcinoma
24. Hodgkin’s Lymphoma
25. Non-Hodgkin's Lymphoma
26. Lung Cancer
27. Pancreatic cancer
28. Prostate cancer
29. Cutaneous tumors with cranial nerve invasion to the base of skull, cavernous sinus and/or brainstem
30. Head and neck cancers requiring ipsilateral radiation treatment (e.g., oral cavity, salivary gland)
31. Mucosal melanoma
32. Adrenal cancers
33. Colon, anal or rectal cancers
34. Bladder cancer
35. Cervical, endometrial or ovarian cancers
36. Skin cancer
37. Palliative treatment

Limitations/Exclusions Proton beam therapy is not considered medically necessary for indications other than those listed above due to insufficient evidence of therapeutic value. Case-by-case consideration will be given for special situations (see diagnostic coding). Revision History 10/10/2025 Reduced age threshold for case-by-case review from 21 to 19 years and younger for members with benign or malignant tumors, or hematologic malignancies, when proton beam therapy is intended for curative treatment
5/17/2024 Expanded covered indications for proton beam therapy to include additional cancerous/noncancerous tumor types, modified case-by-case list, and added clarifications for improved readability 7/14/2023 Added pediatric malignancies and maxillary sinus or paranasal/ethmoid sinus tumors as covered for proton beam therapy Removed notes pertaining to Medicare and added re-direct links to National Government Services [NGS] Local Coverage Determinations
5/7/2021 Amended non-small cell lung cancer (NSCLC) language for SBRT; stage II changed to stage IIA Amended proton beam case-by-case language:  For NSCLC, amended to read “stage II–IIIB” (previously stage IIIB)
 For prostate cancer, amended to read “intact and unoperated” (previously “unoperated”) 4/12/19 Added Commercial and Medicaid coverage of PBT for malignancies requiring craniospinal irradiation (CSI). Added Commercial and Medicaid PBT coverage consideration language for unresectable HCC and intrahepatic cholangiocarcinoma. Added PBT case-by-case review language for Commercial and Medicaid members specific to: Locally advanced breast cancer when treating the internal mammary nodes, primary CNS cancer, esophageal cancer, head and neck cancer (excluding T1-T2N0M0 laryngeal cancer), remaining cases of unresectable HCC and intrahepatic cholangiocarcinoma, Hodgkin’s lymphoma, non-Hodgkin's lymphoma, stage IIIB non-small cell lung cancer, pancreatic cancer, prostate cancer (unoperated), retroperitoneal sarcoma, thymomas and thymic carcinoma. 10/12/18 Added covered indications for malignant primary tumors of the adrenal gland, kidney, liver and pancreas.
Added covered indication for Medicare members (only) presenting with 1–3 kidney or pancreas metastases in the metachronous setting. 1/12/17 Brain metastasis criteria modified for SRS to include Karnofsky scoring, specify lesion size/characteristics and communicate utilization parameters. Neurologic diseases added as covered indications. 12/1/16 Prostate cancer criteria modified for SRBT to include high-risk members. 9/9/2016 For proton beam therapy, separated criteria per line of business. Added Stage IIA seminoma indication for Commercial and Medicaid members; added Group 1 and Group 2 indications for Medicare members. For stereotactic radiosurgery, specific to Medicare members, clarified that prior surgery or conventional radiation therapy is not required in certain instances. 3/11/2016 Added case-by-case language for boost treatment of larger cranial or spinal lesions within the section pertaining to malignant primary tumors/lesions. Applicable Procedure Codes 61796 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion
61797 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 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 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 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 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 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 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; 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 one session) 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 77520 Proton treatment delivery; simple, without compensation
77522 Proton treatment delivery; simple, with compensation 77523 Proton treatment delivery; intermediate 77525 Proton treatment delivery; complex G0339 Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment G0340 Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment S8030 Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy Applicable ICD-10 Diagnosis Codes
Proton Beam
C00.0 Malignant neoplasm of external upper lip C00.1 Malignant neoplasm of external lower lip C00.2 Malignant neoplasm of external lip, unspecified C00.3 Malignant neoplasm of upper lip, inner aspect C00.4 Malignant neoplasm of lower lip, inner aspect C00.5 Malignant neoplasm of lip, unspecified, inner aspect C00.6 Malignant neoplasm of commissure of lip, unspecified C00.8 Malignant neoplasm of overlapping sites of lip C00.9 Malignant neoplasm of lip, unspecified C01 Malignant neoplasm of base of tongue C02.0 Malignant neoplasm of dorsal surface of tongue C02.1 Malignant neoplasm of border of tongue C02.2 Malignant neoplasm of ventral surface of tongue C02.3 Malignant neoplasm of anterior two-thirds of tongue, part unspecified C02.4 Malignant neoplasm of lingual tonsil C02.8 Malignant neoplasm of overlapping sites of tongue C02.9 Malignant neoplasm of tongue, unspecified C03.0 Malignant neoplasm of upper gum

Proton Beam
C03.1 Malignant neoplasm of lower gum C03.9 Malignant neoplasm of gum, unspecified C04.0 Malignant neoplasm of anterior floor of mouth C04.1 Malignant neoplasm of lateral floor of mouth C04.8 Malignant neoplasm of overlapping sites of floor of mouth C04.9 Malignant neoplasm of floor of mouth, unspecified C05.0 Malignant neoplasm of hard palate C05.1 Malignant neoplasm of soft palate C05.2 Malignant neoplasm of uvula C05.8 Malignant neoplasm of overlapping sites of palate C05.9 Malignant neoplasm of palate, unspecified C06.0 Malignant neoplasm of cheek mucosa C06.1 Malignant neoplasm of vestibule of mouth C06.2 Malignant neoplasm of retromolar area C06.80 Malignant neoplasm of overlapping sites of unspecified parts of mouth C06.89 Malignant neoplasm of overlapping sites of other parts of mouth C06.9 Malignant neoplasm of mouth, unspecified C07 Malignant neoplasm of parotid gland C08.0 Malignant neoplasm of submandibular gland C08.1 Malignant neoplasm of sublingual gland C08.9 Malignant neoplasm of major salivary gland, unspecified C09.0 Malignant neoplasm of tonsillar fossa C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior) C09.8 Malignant neoplasm of overlapping sites of tonsil C09.9 Malignant neoplasm of tonsil, unspecified C10.0 Malignant neoplasm of vallecula C10.1 Malignant neoplasm of anterior surface of epiglottis C10.2 Malignant neoplasm of lateral wall of oropharynx C10.3 Malignant neoplasm of posterior wall of oropharynx C10.4 Malignant neoplasm of branchial cleft C10.8 Malignant neoplasm of overlapping sites of oropharynx C10.9 Malignant neoplasm of oropharynx, unspecified C11.0 Malignant neoplasm of superior wall of nasopharynx C11.1 Malignant neoplasm of posterior wall of nasopharynx C11.2 Malignant neoplasm of lateral wall of nasopharynx C11.3 Malignant neoplasm of anterior wall of nasopharynx C11.8 Malignant neoplasm of overlapping sites of nasopharynx C11.9 Malignant neoplasm of nasopharynx, unspecified C12 Malignant neoplasm of pyriform sinus C13.0 Malignant neoplasm of postcricoid region C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect C13.2 Malignant neoplasm of posterior wall of hypopharynx C13.8 Malignant neoplasm of overlapping sites of hypopharynx C13.9 Malignant neoplasm of hypopharynx, unspecified

Proton Beam
C14.0 Malignant neoplasm of pharynx, unspecified C14.2 Malignant neoplasm of Waldeyer's ring C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx C22.0 Liver cell carcinoma C22.2 Hepatoblastoma C22.3 Angiosarcoma of liver C22.4 Other sarcomas of liver C22.7 Other specified carcinomas of liver C22.8 Malignant neoplasm of liver, primary, unspecified as to type C25.0 Malignant neoplasm of head of pancreas C25.1 Malignant neoplasm of body of pancreas C25.2 Malignant neoplasm of tail of pancreas C25.3 Malignant neoplasm of pancreatic duct C25.4 Malignant neoplasm of endocrine pancreas C25.7 Malignant neoplasm of other parts of pancreas C25.8 Malignant neoplasm of overlapping sites of pancreas C25.9 Malignant neoplasm of pancreas, unspecified C30.0 Malignant neoplasm of nasal cavity C30.1 Malignant neoplasm of middle ear C31.0 Malignant neoplasm of maxillary sinus C31.1 Malignant neoplasm of ethmoidal sinus C31.2 Malignant neoplasm of frontal sinus C31.3 Malignant neoplasm of sphenoid sinus C31.8 Malignant neoplasm of overlapping sites of accessory sinuses C31.9 Malignant neoplasm of accessory sinus, unspecified C32.0 Malignant neoplasm of glottis C32.1 Malignant neoplasm of supraglottis C32.2 Malignant neoplasm of subglottis C32.3 Malignant neoplasm of laryngeal cartilage C32.8 Malignant neoplasm of overlapping sites of larynx C32.9 Malignant neoplasm of larynx, unspecified C40.00 Malignant neoplasm of larynx, unspecified C40.01 Malignant neoplasm of scapula and long bones of right upper limb C40.02 Malignant neoplasm of scapula and long bones of left upper limb C40.10 Malignant neoplasm of short bones of unspecified upper limb C40.11 Malignant neoplasm of short bones of right upper limb C40.12 Malignant neoplasm of short bones of left upper limb C40.20 Malignant neoplasm of long bones of unspecified lower limb C40.21 Malignant neoplasm of long bones of right lower limb C40.22 Malignant neoplasm of long bones of left lower limb C40.30 Malignant neoplasm of short bones of unspecified lower limb C40.31 Malignant neoplasm of short bones of right lower limb C40.32 Malignant neoplasm of short bones of left lower limb C40.80 Malignant neoplasm of overlapping sites of bone and articular cartilage of unspecified limb

Proton Beam
C40.81 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb C40.82 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb C41.0 Malignant neoplasm of bones of skull and face C41.1 Malignant neoplasm of mandible C41.2 Malignant neoplasm of vertebral column C41.3 Malignant neoplasm of ribs, sternum and clavicle C41.4 Malignant neoplasm of pelvic bones, sacrum and coccyx C41.9 Malignant neoplasm of bone and articular cartilage, unspecified C45.1 Mesothelioma of peritoneum C45.7 Mesothelioma of other sites C47.0 Malignant neoplasm of peripheral nerves of head, face and neck C48.0 Malignant neoplasm of retroperitoneum C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck C64.1 Malignant neoplasm of right kidney, except renal pelvis C64.2 Malignant neoplasm of left kidney, except renal pelvis C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis C69.00 Malignant neoplasm of unspecified conjunctiva C69.01 Malignant neoplasm of right conjunctiva C69.02 Malignant neoplasm of left conjunctiva C69.10 Malignant neoplasm of unspecified cornea C69.11 Malignant neoplasm of right cornea C69.12 Malignant neoplasm of left cornea C69.20 Malignant neoplasm of unspecified retina C69.21 Malignant neoplasm of right retina C69.22 Malignant neoplasm of left retina C69.30 Malignant neoplasm of unspecified choroid C69.31 Malignant neoplasm of right choroid C69.32 Malignant neoplasm of left choroid C69.40 Malignant neoplasm of unspecified ciliary body C69.41 Malignant neoplasm of right ciliary body C69.42 Malignant neoplasm of left ciliary body C69.50 Malignant neoplasm of unspecified lacrimal gland and duct C69.51 Malignant neoplasm of right lacrimal gland and duct C69.52 Malignant neoplasm of left lacrimal gland and duct C69.60 Malignant neoplasm of unspecified orbit C69.61 Malignant neoplasm of right orbit C69.62 Malignant neoplasm of left orbit C69.80 Malignant neoplasm of overlapping sites of unspecified eye and adnexa C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa C69.90 Malignant neoplasm of unspecified site of unspecified eye C69.91 Malignant neoplasm of unspecified site of right eye C69.92 Malignant neoplasm of unspecified site of left eye

Proton Beam
C70.0 Malignant neoplasm of cerebral meninges C70.1 Malignant neoplasm of spinal meninges C70.9 Malignant neoplasm of meninges, unspecified C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles C71.1 Malignant neoplasm of frontal lobe C71.2 Malignant neoplasm of temporal lobe C71.3 Malignant neoplasm of parietal lobe C71.4 Malignant neoplasm of occipital lobe C71.5 Malignant neoplasm of cerebral ventricle C71.6 Malignant neoplasm of cerebellum C71.7 Malignant neoplasm of brain stem C71.8 Malignant neoplasm of overlapping sites of brain C71.9 Malignant neoplasm of brain, unspecified C72.0 Malignant neoplasm of spinal cord C72.1 Malignant neoplasm of cauda equina C72.20 Malignant neoplasm of unspecified olfactory nerve C72.21 Malignant neoplasm of right olfactory nerve C72.22 Malignant neoplasm of left olfactory nerve C72.30 Malignant neoplasm of unspecified optic nerve C72.31 Malignant neoplasm of right optic nerve C71.32 Malignant neoplasm of left optic nerve C72.40 Malignant neoplasm of unspecified acoustic nerve C72.41 Malignant neoplasm of right acoustic nerve C72.42 Malignant neoplasm of left acoustic nerve C72.50 Malignant neoplasm of unspecified cranial nerve C72.59 Malignant neoplasm of other cranial nerves C72.9 Malignant neoplasm of central nervous system, unspecified C75.0 Malignant neoplasm of parathyroid gland C75.1 Malignant neoplasm of pituitary gland C75.2 Malignant neoplasm of craniopharyngeal duct C75.3 Malignant neoplasm of pineal gland C75.5 Malignant neoplasm of aortic body and other paraganglia C7A.8 Other malignant neuroendocrine tumors C76.0 Malignant neoplasm of head, face and neck C76.1 Malignant neoplasm of thorax C76.2 Malignant neoplasm of abdomen C76.3 Malignant neoplasm of pelvis C76.40 Malignant neoplasm of unspecified upper limb C76.41 Malignant neoplasm of right upper limb C76.42 Malignant neoplasm of left upper limb C76.50 Malignant neoplasm of unspecified lower limb C76.51 Malignant neoplasm of right lower limb C76.52 Malignant neoplasm of left lower limb C76.8 Malignant neoplasm of other specified ill-defined sites

Proton Beam
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct C79.31 Secondary malignant neoplasm of brain D32.0 Benign neoplasm of cerebral meninges D32.1 Benign neoplasm of spinal meninges D32.9 Benign neoplasm of meninges, unspecified D33.0 Benign neoplasm of brain, supratentorial D33.1 Benign neoplasm of brain, infratentorial D33.2 Benign neoplasm of brain, unspecified D33.3 Benign neoplasm of cranial nerves D33.4 Benign neoplasm of spinal cord D33.7 Benign neoplasm of other specified parts of central nervous system D33.9 Benign neoplasm of central nervous system, unspecified D35.2 Benign neoplasm of pituitary gland D35.3 Benign neoplasm of craniopharyngeal duct D35.4 Benign neoplasm of pineal gland D35.6 Benign neoplasm of aortic body and other paraganglia D42.0 Neoplasm of uncertain behavior of cerebral meninges D42.1 Neoplasm of uncertain behavior of spinal meninges D42.9 Neoplasm of uncertain behavior of meninges, unspecified D43.0 Neoplasm of uncertain behavior of brain, supratentorial D43.1 Neoplasm of uncertain behavior of brain, infratentorial D43.2 Neoplasm of uncertain behavior of brain, unspecified D43.4 Neoplasm of uncertain behavior of spinal cord D44.10 Neoplasm of uncertain behavior of unspecified adrenal gland D44.11 Neoplasm of uncertain behavior of right adrenal gland D44.12 Neoplasm of uncertain behavior of left adrenal gland D44.3 Neoplasm of uncertain behavior of pituitary gland D44.4 Neoplasm of uncertain behavior of craniopharyngeal duct D44.5 Neoplasm of uncertain behavior of pineal gland D44.6 Neoplasm of uncertain behavior of carotid body D44.7 Neoplasm of uncertain behavior of aortic body and other paraganglia D49.6 Neoplasm of unspecified behavior of brain D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system G95.20 Unspecified cord compression G95.29 Other cord compression G95.9 Disease of spinal cord, unspecified Q28.2 Arteriovenous malformation of cerebral vessels Q28.3 Other malformations of cerebral vessels Z92.3 Personal history of irradiation

Gamma Knife, LINAC C33 Malignant neoplasm of trachea C34.00 Malignant neoplasm of unspecified main bronchus

Gamma Knife, LINAC C34.01 Malignant neoplasm of right main bronchus C34.02 Malignant neoplasm of left main bronchus C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung C34.11 Malignant neoplasm of upper lobe, right bronchus or lung C34.12 Malignant neoplasm of upper lobe, left bronchus or lung C34.2 Malignant neoplasm of middle lobe, bronchus or lung C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.32 Malignant neoplasm of lower lobe, left bronchus or lung C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung C34.91 Malignant neoplasm of unspecified part of right bronchus or lung C34.92 Malignant neoplasm of unspecified part of left bronchus or lung C40.80 Malignant neoplasm of overlapping sites of bone and articular cartilage of unspecified limb C40.81 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb C40.82 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb C40.90 Malignant neoplasm of unspecified bones and articular cartilage of unspecified limb C40.91 Malignant neoplasm of unspecified bones and articular cartilage of right limb C40.92 Malignant neoplasm of unspecified bones and articular cartilage of left limb C41.0 Malignant neoplasm of bones of skull and face C41.9 Malignant neoplasm of bone and articular cartilage, unspecified C61 Malignant neoplasm of prostate C64.1 Malignant neoplasm of right kidney, except renal pelvis C64.2 Malignant neoplasm of left kidney, except renal pelvis C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis C69.40 Malignant neoplasm of unspecified ciliary body C69.41 Malignant neoplasm of right ciliary body C69.42 Malignant neoplasm of left ciliary body C70.0 Malignant neoplasm of cerebral meninges C70.1 Malignant neoplasm of spinal meninges C70.9 Malignant neoplasm of meninges, unspecified C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles C71.1 Malignant neoplasm of frontal lobe C71.2 Malignant neoplasm of temporal lobe C71.3 Malignant neoplasm of parietal lobe C71.4 Malignant neoplasm of occipital lobe C71.5 Malignant neoplasm of cerebral ventricle C71.6 Malignant neoplasm of cerebellum C71.7 Malignant neoplasm of brain stem C71.8 Malignant neoplasm of overlapping sites of brain C71.9 Malignant neoplasm of brain, unspecified C72.0 Malignant neoplasm of spinal cord

Gamma Knife, LINAC C72.1 Malignant neoplasm of cauda equina C72.20 Malignant neoplasm of unspecified olfactory nerve C72.21 Malignant neoplasm of right olfactory nerve C72.22 Malignant neoplasm of left olfactory nerve C72.30 Malignant neoplasm of unspecified optic nerve C72.31 Malignant neoplasm of right optic nerve C72.32 Malignant neoplasm of left optic nerve C72.40 Malignant neoplasm of unspecified acoustic nerve C72.41 Malignant neoplasm of right acoustic nerve C72.42 Malignant neoplasm of left acoustic nerve C72.50 Malignant neoplasm of unspecified cranial nerve C72.59 Malignant neoplasm of other cranial nerves C72.9 Malignant neoplasm of central nervous system, unspecified C74.00 Malignant neoplasm of cortex of unspecified adrenal gland C74.01 Malignant neoplasm of cortex of right adrenal gland C74.02 Malignant neoplasm of cortex of left adrenal gland C74.10 Malignant neoplasm of medulla of unspecified adrenal gland C74.11 Malignant neoplasm of medulla of right adrenal gland C74.12 Malignant neoplasm of medulla of left adrenal gland C74.90 Malignant neoplasm of unspecified part of unspecified adrenal gland C74.91 Malignant neoplasm of unspecified part of right adrenal gland C74.92 Malignant neoplasm of unspecified part of left adrenal gland C75.1 Malignant neoplasm of pituitary gland C75.2 Malignant neoplasm of craniopharyngeal duct C75.3 Malignant neoplasm of pineal gland C75.5 Malignant neoplasm of aortic body and other paraganglia C79.31 Secondary malignant neoplasm of brain C79.32 Secondary malignant neoplasm of cerebral meninges C79.40 Secondary malignant neoplasm of unspecified part of nervous system C79.49 Secondary malignant neoplasm of other parts of nervous system D02.20 Carcinoma in situ of unspecified bronchus and lung D02.21 Carcinoma in situ of right bronchus and lung D02.22 Carcinoma in situ of left bronchus and lung D16.4 Benign neoplasm of bones of skull and face D18.02 Hemangioma of intracranial structures D32.0 Benign neoplasm of cerebral meninges D32.1 Benign neoplasm of spinal meninges D32.9 Benign neoplasm of meninges, unspecified D33.0 Benign neoplasm of brain, supratentorial D33.1 Benign neoplasm of brain, infratentorial D33.2 Benign neoplasm of brain, unspecified D33.3 Benign neoplasm of cranial nerves D33.7 Benign neoplasm of other specified parts of central nervous system D33.9 Benign neoplasm of central nervous system, unspecified

Gamma Knife, LINAC D35.2 Benign neoplasm of pituitary gland D35.3 Benign neoplasm of craniopharyngeal duct D35.4 Benign neoplasm of pineal gland D42.0 Neoplasm of uncertain behavior of cerebral meninges D42.1 Neoplasm of uncertain behavior of spinal meninges D42.9 Neoplasm of uncertain behavior of meninges, unspecified D43.0 Neoplasm of uncertain behavior of brain, supratentorial D43.1 Neoplasm of uncertain behavior of brain, infratentorial D43.2 Neoplasm of uncertain behavior of brain, unspecified D43.4 Neoplasm of uncertain behavior of spinal cord D49.6 Neoplasm of unspecified behavior of brain D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system G50.0 Trigeminal neuralgia Q28.0 Arteriovenous malformation of precerebral vessels Q28.2 Arteriovenous malformation of cerebral vessels Q28.3 Other malformations of cerebral vessels Z92.3 Personal history of irradiation

References
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