DescriptionStereotactic radiosurgery (SRS) is a form of radiation therapy in which three- dimensional (3D) images are utilized to specifically direct focused radiation to obliterate abnormal tissues in the head and neck (facilitated by a rigid head frame), while sparing surrounding healthy tissue. This technique differs from conventional radiation therapy, which involves exposing large areas of tissue to relatively broad fields of radiation. SRS can be utilized for, but may not be limited to, the treatment of arteriovenous malformations (AVMs), aneurysms, benign or malignant brain tumors and acoustic neuromas (vestibular schwannoma).Page: 1 of 30Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0395-023 Page: 2 of 30Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Stereotactic body radiation therapy (SBRT) is similar in technique to intracranial SRS except the target areas are in the body (utilizing a body frame) and do not include the head or neck (extracranial). SBRT involves a single high-dose radiation delivery, or a series of fractionated radiation deliveries given over several days, with the intention of decreasing the short and long-term side effects of radiation therapy, while permitting a higher total radiation dosage in some situations.Delivery systems for SRS and SBRT include, but may not be limited to:• CyberKnife is a radiation delivery system that consists of a lightweight linear accelerator device (LINAC) that is mounted to a multijointed robotic arm. This device utilizes a proprietary real-time image-guidance system to deliver SRS or radiotherapy. It was designed to access hard to reach or complex shaped tumors that may not be accessible by surgery and other radiosurgical technologies.• Gamma Knife (eg, Akesis Galaxy and Akesis Galaxy RTi, Elekta Esprit, Gamma Knife Icon Leksell, Perfexion SRS system,) is a radiosurgery technology, which is designed to treat brain tumors. The device utilizes ionizing radiation (gamma rays) produced by 201 radioactive colbalt-60 sources to ablate intracranial targets via a fixed stereotactic frame.• GammaPod is a stereotactic radiotherapy system that is designed to deliver SBRT by purportedly using thousands of individual focused beams from 36 rotating radioactive Cobalt-60 sources. It is intended for use in the noninvasive stereotactic delivery of radiation to a portion of the breast in conjunction with breast conserving treatment. The individual lies prone on a table with the breast immobilized in a vacuum-assisted cup, which reportedly provides increased accuracy in the delivery of the radiation.163 (Refer to Coverage Limitations section)The placement of a transperineal biodegradable spacer (eg, Barrigel, SpaceOAR, SpaceOAR Vue) positions the anterior (frontal) section of the rectal wall away from the prostate during external beam radiotherapy treatments for prostate cancer with the goal of limiting the radiation exposure to the anterior rectum. Because this material is biodegradable, it is absorbed over time by the individual’s body. SpaceOAR is comprised of a synthetic, absorbable polyethylene glycol-based hydrogel. SpaceOAR Vue contains PEGylated iodine, which is designed to enhanceStereotactic Radiosurgery and Stereotactic Body Radiation Therapy Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0395-023 Page: 3 of 30Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.visibility via CT scan. Barrigel injectable gel is similar to the SpaceOAR product; however, it is made of stabilized hyaluronic acid.For information regarding coverage determination/limitations not addressed in this medical coverage policy, please refer to the following:
| Service | Corresponding Medical Coverage Policies | | Transperineal biodegradable | Brachytherapy |
| spacers | Intensity Modulated Radiation Therapy |
| Stereotactic radiation therapy for ventricular tachycardia | Cardiac Electrophysiological Studies and Cardiac Catheter Ablation |
| Proton beam radiation (immobilization and imaging) | Proton Beam, Neutron Beam and Carbon lor Radiation Therapy |
Corresponding Medical Coverage Policies Brachytherapy Intensity Modulated Radiation Therapy Cardiac Electrophysiological Studies and Cardiac Catheter Ablation Proton Beam, Neutron Beam and Carbon Ion Radiation TherapyCoverage DeterminationHumana members may be eligible under the Plan for SRS for the following indications:• Arteriovenous malformations (AVMs)o AVM of the brain less than 3 cm in size; ANDIndividual is a poor surgical risk; OR Surgically inaccessible AVM; OR• Brain malignancies (primary or metastatic)o Four or fewer lesions; ANDo Karnofsky Performance Status score between 80 and 100; ANDo No active systemic disease (defined as extracranial disease that is stable or in remission); OR• Disabling tremor in an individual with Parkinson’s diseaseo Not amenable for alternative procedures (eg, deep brain stimulation) (for information regarding coverage determination/limitations for deep brainStereotactic Radiosurgery and Stereotactic Body Radiation Therapy Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0395-023 Page: 4 of 30Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.stimulation, please refer to Deep Brain Stimulation and Cortical Stimulation Medical Coverage Policy); ANDo Symptoms refractory to medical therapy; OR• Intracranial tumors (eg, acoustic neuromas; also known as vestibular schwannomas)o Not amenable to surgical interventions; OR o Not completely resectable or unresectable; OR• Ocular melanomaso Not amenable to conventional forms of treatment (eg, brachytherapy, proton beam); ORo Not amenable to surgical excision; OR• Pituitary adenomaso Adjuvant to partial resection; OR o Not amenable to surgical interventions; OR o Recurrence of tumor; OR• Severe essential tremoro Not amenable for alternative procedures (eg, deep brain stimulation) (for information regarding coverage determination/limitations for deep brain stimulation, please refer to Deep Brain Stimulation and Cortical Stimulation Medical Coverage Policy); ANDo Symptoms refractory to medical therapy; OR• Trigeminal neuralgiao Not amenable to surgical excision; OR o Symptoms refractory to medical therapyStereotactic Radiosurgery and Stereotactic Body Radiation Therapy Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0395-023 Page: 5 of 30Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Humana members may be eligible under the Plan for SBRT for the following indications:• Hepatocellular carcinomao Karnofsky Performance Status score between 80 and 100; ANDNonmetastatic, unresectable disease not suitable for liver transplantation; ORNot amenable to surgical interventions due to comorbidity; OR• Non-small cell lung cancero Inoperable stage 1 node negative peripheral lesions that are less than 5 cm in maximal dimension (T1aN0, T1bN0 or T2aN0 disease); ORo Limited lung metastasis (T1aN1, T1bN1 or T2aN1 disease); OR• Prostate cancero Gleason grade less than or equal to 6; AND o Life expectancy of 10 years or greater; AND o Organ-confined prostate cancer; AND o Prostate-specific antigen (PSA) less than 10; OR• Spinal tumorso Not amenable to surgical excisionHumana members may be eligible under the Plan for the placement of a transperineal biodegradable spacer (eg, Barrigel, SpaceOAR, SpaceOAR Vue) for individuals receiving external beam radiation therapy (EBRT), which includes SBRT, for prostate cancer in the absence of contraindications.Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0395-023 Page: 6 of 30Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Coverage LimitationsHumana members may NOT be eligible under the Plan for SRS/SBRT for any indications other than those listed above including, but may not be limited to:Bone metastasis; OR • Breast cancer; OR • Cholangiocarcinoma; OR • Colon/rectal cancer; OR • Epilepsy; OR • Gynecologic cancer (eg, cervical, endometrial, vulvar) OR; • Kidney/renal cancer; OR • Pancreatic cancer; OR • Soft tissue sarcoma; OR • Thyroid cancerThese are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.Humana members may NOT be eligible under the Plan for GammaPod. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer- reviewed medical literature published in the English language.Humana members may NOT be eligible under the Plan for placement of a transperineal biodegradable spacer (eg, Barrigel, SpaceOAR, SpaceOAR Vue) utilized during EBRT for any indications not listed above or for the following contraindications:• Bleeding (eg, platelet abnormalities) or coagulation (eg, thrombocytopenia) disorders83; OR• Locally advanced prostate cancer (spread outside the prostate gland to nearby tissues [eg, lymph nodes, seminal vesicles])83; OR• Rectal invasion with a T3 class tumor or posterior extension115Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0395-023 Page: 7 of 30Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.Additional information about cancer and movement disorders may be found from the following websites: BackgroundAmerican Association of Neurological Surgeons • American Cancer Society • National Comprehensive Cancer Network • National Library of MedicineMedical AlternativesAlternatives to SRS and SBRT include, but may not be limited to, the following:• Chemotherapy• Deep brain stimulation (please refer to Deep Brain Stimulation and Cortical Stimulation Medical Coverage Policy)• Endovascular embolization• Intensity modulated radiation therapy (IMRT) (please refer to Intensity Modulated Radiation Therapy Medical Coverage Policy)• Prescription drug therapy• Proton beam radiation therapy (please refer to Proton Beam, Neutron Beam and Carbon Ion Radiation Therapy Medical Coverage Policy)• Radiotherapy• Surgical removalPhysician consultation is advised to make an informed decision based on an individual’s health needs.Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0395-023 Page: 8 of 30Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.
| cPT® Code(s) | Description | Comments | | 32701 | Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment | |
| 55874 | Transperineal placement of biodegradable material, peri- prostatic, single or multiple injection(s), including image guidance, when performed | |
| 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 ; F 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 | |
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0395-023 Page: 9 of 30Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
| 77372 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based | |
| 77373 | . ae . Stereotactic body radiation therapy, treatment delivery, per . F F oe . ; fraction to 1 or more lesions, including image guidance, entire , course not to exceed 5 fractions | Not Covered if used to report any therapy . . outlined in Coverage we . Limitations section |
| 77432 | Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) | |
| 77435 | Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions | |
| CPT® Category Ill Code(s) | Description | Comments |
| No code(s) identified |
| HCPCS Code(s) | . ue Description | Comments |
| C1889 | Implantable/insertable device, not otherwise classified | |
| 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 | |
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When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Appendix A Karnofsky Performance Status Criteria Able to carry on normal activity and to work; no special care needed.
| Able to carry on normal | | Normal, no complaints; no evidence of disease |
| activity and to work; no special care needed. | | Able to carry on normal activity; minor signs or symptoms of disease |
| | Normal activity with effort; some signs or symptoms of disease |
| Unable to work; able to live at home and care for most | | Cares for self; unable to carry on normal activity or to do active work |
| personal needs; varying amount of assistance needed. | | Requires occasional assistance but is able to care for most of personal needs |
| | Requires considerable assistance and frequent |
| Unable to care for self; | | medical care Disabled; requires special care and assistance |
| requires equivalent of institutional or hospital care; | | Severely disabled; hospital admission is indicated although death not imminent |
| disease may be progressing | 20 | Moribund; fatal processes progressing rapidly |
| rapidly. | | Dead |
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Effective Date: 08/24/2023 Revision Date: 08/24/2023 Review Date: 08/24/2023 Policy Number: HUM-0395-023 Page: 30 of 30Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.Appendix B TNM Staging System85 The T category describes the original (primary) tumor. TX T0 Tis T1-T4
| TX | Primary tumor cannot be evaluated |
| TO | No evidence of primary tumor |
| Tis | Carcinoma in situ (early cancer that has not spread to neighboring tissue) |
| T1-T4 | Size and/or extent of the primary tumor |
The N category describes whether the cancer has reached nearby lymph nodes NX N0 N1-N3
| NX | f$ Regional lymph nodes cannot be evaluated |
| NO | No regional lymph node involvement (no cancer found in the lymph nodes) |
| N1-N3 | Involvement of regional lymph nodes (number and/or extent of spread) |
The M category tells whether there are distant metastases M0 M1
Appendix C Gleason Grading System Grade Group 1 2 3 4 5
| Grade Group | Gleason Score | Gleason Pattern | | Less than or equal to 6 | Less than or equal to 3+3 |
| BIWIN]R | 7 | 344 |
| 7 | 4+3 |
| 8 | 4+4, 3+5, 5+3 |
| WO) | 9 or 10 | 4+5,5+4,5+5 |