Point32 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy(Eff. beginning 1.1.24) Form

Stereotactic radiosurgery (SRS)

Stereotactic radiosurgery (SRS) is similar in concept to SBRT and refers to stereotactically guided radiation therapy delivered to intracranial targets and selected tumors near the base of the skull. Stereotactic radiosurgery (SRS) delivers a single or very limited number of fractions of high dose of radiation to a well-defined tumor volume, rather than repeated small fractions to both cancer and normal cells.

Stereotactic body radiation therapy (SBRT)

Stereotactic body radiation therapy (SBRT) is a radiation treatment modality that couples a high degree of anatomic targeting accuracy and reproducibility with very high doses of extremely precise, externally generated, ionizing radiation. The therapeutic intent of SBRT is to maximize cell-killing effect on the target(s) while minimizing radiation-related injury in adjacent normal tissues. Stereotactic body radiation therapy refers to multifractional (typically two to five fractions) treatment of intracranial, spinal, or extracranial sites, such as the lung, head and neck, liver, pancreas, and prostate. SBRT can also be used for the treatment of oligometastatic disease.

Clinical Guideline Coverage Criteria

The Plan uses guidance from the Centers for Medicare and Medicaid Services (CMS) and MassHealth for coverage determinations for its Dual Product Eligible plan members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals and MassHealth Medical Necessity Determinations are the basis for coverage determinations where available. For Tufts Health One Care plan members the following criteria is used:

Stereotactic Radiation Therapy: Stereotactic radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

LCD L35076 2112930

Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

1. The Plan may authorize the coverage of stereotactic radiosurgery (SRS) when the Member meets ONE of the following:
   • Small intracranial or spinal arteriovenous malformations and the Member is considered a poor surgical candidate
   • Primary intracranial tumors not suitable for complete surgical resection or the Member has failed conventional therapy
   • Metastatic brain lesion(s) and the Member is with good performance status (Karnofsky Performance Status of ≥70% or Eastern Cooperative Oncology Group (ECOG) Status ≤2)
   • Vestibular schwannoma or acoustic neurofibromatosis not amenable to surgical resection
   • Pituitary adenoma
   • Craniopharyngioma
   • Glomus jugulare tumors
   • Hemangiomas of the brain
   • Meningioma
   • Pineal gland tumors
   • Uveal or ocular melanoma
   • Trigeminal neuralgia and glossopharyngeal neuralgia refractory to treatment.
2. The Plan may authorize the coverage of definitive stereotactic body radiation therapy (SBRT) for treatment of primary non-metastatic lesions listed below when ALL of the following criteria are met:
   • A high level of precision and accuracy or a high dose per fraction is necessary to minimize the risk of injury to surrounding normal tissues and treatment with conventional methods is not appropriate or safe for the Member; AND
   • Member is with good performance status (Karnofsky Performance Status of ≥70% or Eastern Cooperative Oncology Group (ECOG) Status ≤2); AND
   • The Member is with ONE of the following:
     1. Prostate cancer without evidence of distant metastasis (Up to six treatment sessions may be authorized for this diagnosis); or
     2. Stage I or II non-small cell lung cancer and ONE of the following is met:
        • when SBRT is requested as an alternative to surgery for Member who is a high surgical risk or who refuses surgery after surgical consultation;
        • Pancreatic adenocarcinoma without evidence of distant metastasis; or
        • Hepatocellular carcinoma without evidence of regional or distant metastasis

The Plan may authorize the coverage of stereotactic body radiation therapy (SBRT) for the treatment of bone metastases (including vertebral) when the Member has persistent or recurrent bone pain after a standard course of EBRT. The Plan may authorize the coverage of stereotactic body radiation therapy (SBRT) for the treatment of oligometastatic disease of extracranial sites when ALL of the following criteria are met:

1. Primary tumor is breast, colorectal, melanoma, non-small cell lung, prostate, renal cell or sarcoma; and
2. ≤ 5 metastatic lesions; and
3. A controlled primary tumor: defined as at least 3 months since original tumor was treated definitively, with no progression at primary site; and
4. All metastatic sites are safely treatable; and
5. Member is with good performance status (Karnofsky Performance Status of ≥70% or Eastern Cooperative Oncology Group (ECOG) Status ≤2); and
6. No documentation of evidence of malignant pleural effusion, leptomeningeal or peritoneal carcinomatosis.

Karnofsky performance status measures

• Score Definition
• 100 - Normal; no complaints; no evidence of disease.
• 90 - Able to carry on normal activity; minor signs or symptoms of disease.
• 80 - Normal activity with effort; some signs or symptoms of disease.
• 70 - Cares for self; unable to carry on normal activity or to do active work.
• 60 - Requires occasional assistance, but is able to care for most of their personal needs.
• 50 - Requires considerable assistance and frequent medical care.
• 40 - Disabled; requires special care and assistance.
• 30 - Severely disabled; hospital admission is indicated although death not imminent.
• 20 - Very sick; hospital admission necessary; active supportive treatment necessary.
• 10 - Moribund; fatal processes progressing rapidly.
• 0 - Dead

Eastern Cooperative Oncology Group (ECOG)

• Score Definition
• 0 – Asymptomatic. Fully active, able to carry on all pre-disease activities without restriction
• 1 – Symptomatic but completely ambulatory. Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (e.g., light housework, office work).
• 2 – Symptomatic, <50% in bed during the day. Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours.
• 3 – Symptomatic, >50% in bed, but not bedbound. Capable of only limited self-care, confined to bed or chair 50% or more of waking hours.
• 4 – Bedbound. Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
• 5 – Death