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Medical Policy Revision: Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Effective March 15, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for stereotactic radiosurgery and stereotactic body radiation therapy.

According to the guidelines of our medical policy, Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy:

Stereotactic radiosurgery (SRS) using a gamma or LINAC unit is generally considered medically necessary for:

  • Arteriovenous malformations
  • Acoustic neuromas
  • Schwannomas
  • Pituitary adenomas
  • Non-resectable, residual or recurrent meningiomas
  • Craniopharyngiomas
  • Hemangioblastomas
  • Pineocytomas
  • Glomus jugulare tumors
  • Brain metastases (partial brain radiotherapy with SRS)
  • Primary malignancies of the central nervous system (CNS), including but not limited to, high-grade gliomas (initial treatment or treatment of recurrence)
  • Re-treatment for salvage after prior radiation in cases of recurrent or persistent head and neck cancer in members who have no evidence of metastatic disease
  • Neurologic diseases that are refractory to medical treatment and/or neurosurgery including epilepsy, movement disorders (Parkinson's disease and essential tremor, familial tremor classifications with major systemic disease) and trigeminal neuralgia

Stereotactic body radiotherapy (SBRT) is generally considered medically necessary for:

  • Patients with stage T1 or T2a non-small cell lung cancer (tumor not larger than 5 cm) showing no nodal or distant disease and who are not candidates for surgical resection;
  • Spinal or vertebral body tumors (metastatic or primary) in patients who have received prior radiation therapy
  • Spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma)
  • Prostate cancer (when certain criteria are met)
  • Extra-cranial oligometastases (in certain clinical situations)

When SRS or SRBT is performed using fractionation for the medically necessary indications noted above, it would also be considered medically necessary.

Investigational applications of SRS include, but are not limited to, chronic pain.

SBRT is considered investigational in the treatment of extracranial sites, except for the indications noted above.

We encourage you to review this revised policy in our online Medical Policy Manual.

Based on the guidelines of our medical policy, Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy, AND the submitted diagnosis code(s):

  • CPT® codes 32701, 77371, 77372, 77432, or HCPCS codes G0339, G0340, submitted on claims for services provided on and after March 15, 2016 may be denied as investigational services.
     
  • Claims for services provided on and after March 15, 2016 that include CPT add-on codes +61797, +61799, +61800 or +63621 may pend while information to determine medical appropriateness is requested and reviewed.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after March 15, 2016.

CPT® is a registered mark of the American Medical Association.
 

Published on: December 16, 2015, 11:00 a.m. ET
Last updated on: November 24, 2020, 23:49 p.m. ET