Stereotactic radiosurgery (SRS) is considered eligible when performed for the following conditions:

• pancreatic tumors;
• non-resectable early stage non-small cell lung cancer;
• arteriovenous malformations;
• acoustic neuromas;
• pituitary adenomas;
• non-resectable, residual, or recurrent meningiomas;
• 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);
• primary malignancies of the central nervous system, such as high-grade gliomas (initial treatment or treatment of recurrence), vestibular schwannomas, chordomas, chondrosarcomas, oligodendrogliomas;
• craniopharyngiomas;
• neoplasms of the pineal gland;
• nasopharyngeal or paranasal sinus malignancies;
• hemangiomas;
• trigeminal neuralgia refractory to medical management;
• secondary malignant neoplasm of other specified parts of the nervous system.

SRS is also covered for the following indications:

• Lesions that have been treated previously with radiotherapy or are immediately adjacent to previously irradiated fields. This includes:
  • bony lesions of the spine that have failed external beam radiation;
  • recurring or previously irradiated cancers of the spine and spinal cord;
  • non-radiosensitive melanoma; and,
  • renal cell cancer with metastasis to the spine. In this instance, the additional precision of SRS is required to avoid unacceptable tissue radiation;
• Recurring or previously irradiated tumors of the head and neck with metastasis to other critical organs or structures.

Stereotactic radiosurgery is considered investigational when used to treat all other conditions or disorders. A participating, preferred, or network provider can bill the member for the denied services.

Description

Stereotactic radiosurgery is a technique for delivering a high dose of radiation to a specific tumor target while sparing surrounding healthy tissue and/or organs. This method uses externally generated radiation to treat a defined target in the head or spine without the need to make an incision. The adjective “stereotactic” describes a method during which a target lesion or tumor is localized using either a rigid frame attached to a patient, a system of implanted fiducials or markers, or a similar system. Stereotactic radiosurgery is typically performed in a single session, usually requiring no more than an overnight stay. When treatment is administered over a period of several days, it is referred to as a “fractionated” based on the radiobiologic principle that fractionation decreases the short- and long-term side effects of radiation therapy. In some settings, this permits higher total dosage to be given.

Recent advances in radiation dose planning software, neurodiagnostic imaging and guidance procedures, and the use of robotics have contributed to a new “frameless” stereotactic method of radiation delivery. These improved methods facilitate radiation treatment delivery to both intra- and extracranial anatomic areas for which stereotactic treatment methods may be indicated. Image-guided radiosurgery (IGRS) and radiotherapy (IGRT) are terms for radiation delivery techniques that vary the amount of radiation delivered to a specific target or tumor, using imaging guidance to ensure the precision of the radiation dose to the target tumor or lesion.

There are various FDA-approved devices that can be used to perform stereotactic radiosurgery.  Examples include gamma knife system or linear accelerators (LINACs), such as the Peacock System, Trilogy, Synergy, and CyberKnife. These  systems use real-time imaging guidance to localize the target by identifying internal anatomic landmarks, such as implanted markers (referred to as “fiducials”), and compares their placement with a prior treatment planning CT scan. This eliminates the need for a head frame or other skeletal fixation. Under imaging guidance, the precise tumor position is communicated to the robotic arms that align the radiation beam with the intended target. Then, radiation beams of modulated intensity are aimed at the tumor target from different directions sparing normal tissue and/or organs.

For additional information and coverage criteria pertaining to stereotactic body radiation therapy (SBRT), please refer to Medical Policy Bulletin R-14.

For information and coverage criteria pertaining to proton beam radiation therapy, please refer to Medical Policy Bulletin R-18.

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.

12/2006, Stereotactic radiosurgery and stereotactic radiotherapy covered for certain conditions
10/2007, Coverage for stereotactic radiosurgery expanded
02/2011, Coverage for stereotactic radiosurgery and stereotactic body radiation therapy expanded

American Society of Therapeutic Radiology and Oncology (ASTRO)

Radiosurgery Techniques and Current Devices, Progress in Neurological Surgery, Vol. 20, 2007

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy:  An Overview of Technical Considerations and Clinical Applications, Hematology/Oncology Clinics of North America, 02/2006

Image-Guided Radiosurgical Ablation of Intra- and Extra-Cranial Lesions, Technology in Cancer Research and Treatment, 08/2006

Linear Accelerator Radiosurgery for Vestibular Schwannomas, Journal of Neurosurgery, 11/2006

Radiosurgery for Miscellaneous Skull Base Tumor, Progress in Neurological Surgery, Vol. 20, 2007

Gamma Knife Radiosurgery in the Management of Malignant Melanoma Brain Metastases, Neurosurgery, 03/2007

Stereotactic Radiosurgery Plus Whole-Brain Radiation Therapy vs. Stereotactic Radiosurgery Alone for Treatment of Brain Metastases, Journal of the American Medical Association, 06/2006

CyberKnife Radiosurgery for Spinal Neoplasms, Progress in Neurological Surgery, Vol. 20, 2007

Radiosurgery for Spinal Metastases, Spine, 02/2007

Radiosurgery for the Treatment of Spinal Lung Metastases, Cancer, 12/2006

Radiosurgery for the Treatment of Spinal Melanoma Metastases, Stereotactic and Functional Neurosurgery, Vol. 83, 2005

National Blue Cross Blue Shield Association MPRM 6.01.10

Gerstzen PA, Burton SA, Welch WC, Brufsky AM, et al. Single-fraction radiosurgery for the treatment of spinal breast metastases. Cancer. 2005;104(10):2244-2254. 

Gerstzen PC, Burton SA, Quinn AE, Agarwala SS, Kirkwood JM. Radiosurgery for the Treatment of Spinal Melanoma Metastases. Stereotact Funct Neurosurg. 2005;83:213-221.

Gerstzen PC, Burton SA, et al. Radiosurgery for the Treatment of Spinal Lung Metastases. Cancer. 2006;193-199. 

Gagnon GJ, Henderson FC, Gehan EA, et al. Cyberknife for breast cancer spine metastases. Cancer. 2007;110(8):1796-1802. 

Gerstzen PC, Burton SA, Ozhasoglu C, Welch WC. Radiosurgery for Spinal Metastases. Spine. 2007;32(2):193-199.

Niranjan A, Jawahar A, Kondziolka D, Lunsford LD. A Comparison of Surgical Approaches for the Management of Tremor: Radiofrequency Thalamotomy, Gamma Knife Thalamotomy and Thalamic Stimulation. Stereotact Funct Neurosurg. 1999;72:178-184.

Ohye C, Shibazaki T, Ishihara J, Zhang J. Evaluation of Gamma Thalamotomy for Parkinsonian and Other Tremors: Survival of Neurons Adjacent to the Thalamic Lesion After Gamma Thalamotomy. J Neurosurg. December 2000;93(Suppl 3):120-127.

Friehs GM, et al. Stereotactic Radiosurgery for Functional Disorders. Neurosurg Focus. 2007;23(6):E3.

Kondziolka D, et al. Gamma Knife Thalamotomy for Essential Tremor. J Neurosurg. 2008;108:111-117.

Kondziolka D, Ong JG, Lee JYK, Moore RY, Flickinger JC, Lunsford LD. Gamma Knife Thalamotomy for Essential Hypertension. J Neurosurg. 108:111-117;2008.

Young RF, Li F, Vermeulen S, Meier R. Gamma Knife Thalamotomy for Treatment if Essential Tremor: Long-term Results. J Neurosurg. Nov 2009 (Epub ahead of print).

Elaimy AL, et al. Gamma Knife Radiosurgery for Essential Tremor: A Case Report and Review of the Literature. World J Surg Oncol. 2010;8:20.

Elaimy AL, et al. Gamma Knife Radiosurgery for Movement Disorders: A Concise Review of the Literature. World J Surg Oncol. 2010;8:61.