Stereotactic radiosurgery (SRS) and stereotactic radiotherapy are considered eligible when performed for the following conditions:

• arteriovenous malformations (747.81)
• acoustic neuromas (225.1)
• pituitary adenomas (227.3)
• non-resectable, residual, or recurrent meningiomas (225.2)
• solitary or multiple brain metastases in patients having good performance status and no active systemic disease (defined as extracranial disease that is stable or in remission) (191.0-191.9)
• primary malignancies of the central nervous system, including but not limited to high-grade gliomas (initial treatment or treatment of recurrence)
• trigeminal neuralgia refractory to medical management (350.1)

SRS and stereotactic radiotherapy are considered investigational when used to treat all other conditions or disorders, including but not limited to epilepsy, chronic pain, and for treatment of extracranial sites. A participating, preferred, or network provider can bill the member for the denied services.

Description

SRS delivers high doses of ionizing radiation to small intracranial targets with the use of a head frame. This technique differs from other methods of treatment with radiation. SRS uses highly-focused convergent beams of radiation in a single session. Only the desired target is radiated, sparing adjacent structures or tissue. SRS is typically performed in one session, usually requiring no more than an overnight stay.

SRS can be performed using various devices that deliver the radiation using different energy sources, for example: the Gamma Knife (gamma-ray), a linear accelerator (LINAC), or charged particle sources such as proton or neutron beam.

Stereotactic radiotherapy is the stereotactically guided delivery of radiation treatment in multiple fractions over the course of several days rather than in one session. This fractionated form of radiation therapy can also be delivered using recently developed noninvasive repositioning devices instead of a head frame.

NOTE:

For information and coverage criteria pertaining to non-stereotactic applications or uses of particle beam radiation therapy, please refer to Highmark Medical Policy Bulletins R-18 for proton beam radiation therapy, or R-19 for neutron beam radiation therapy.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PRN References

12/2006, Stereotactic radiosurgery and stereotactic radiotherapy covered for certain conditions

MPRM 6.01.10