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| Medical Policy: | R-21-018 |
| Topic: | Radiation Therapy for Brain Metastases |
| Section: | Radiation Therapy & Nuclear Medicine |
| Effective Date: | August 1, 2018 |
| Issue Date: | July 30, 2018 |
| Last Reviewed: | May 2018 |
Many patients develop brain metastases late in the course of their disease when progressive extracranial disease dictates survival. Options for the type of radiation therapy include whole brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS); and their use depends on associated risk factors. The clinical response rate, degree of response, and duration of response depend on the extent of tumor and the severity of initial neurologic deficits. |
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.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
WBRT for Brain Metastases
- Up to fifteen (15) fractions of WBRT using radiation planned with complex isodose technique may be considered medically necessary.
- For an individual identified as possibly having a poorer survival using methods (e.g. Graded Prognostic Assessement (GPA), presence of poor prognostic factors), a shorter course of up to ten (10) fractions of WBRT may be considered medically necessary
- Three-dimensional (3D) conformal planning, intensity-modulated radiation therapy (IMRT), and image guided therapy (IGRT) are considered not medically necessary.
SRS for Brain Metastases
- Stereotactic radiosurgery may be considered medically necessary when:
- KPS is greater than 70; and
- Systemic disease is under control or good options for systemic treatment are available; and
- No diagnosis of leptomenigeal disease; and
- Primary histology is not germ cell, small cell, or lymphoma
- Initial treatment with SRS for brain metastases may be considered medically necessary when ALL of the following conditions are met:
- No lesion is greater than 5cm and all leisons can be treated in a single treatment plan in a single fraction (or SRS) or up to five (5) fractions (for fractionated SRS); and
- Note that ALL lesions present on imaging must be targeted as a single episode of care. If this cannot be accomplished in a maximum of five (5) fractions, each fraction must be billed as 3D conformal or IMRT, depending on the planning, as the definition of SRS is not met.
- In an individual who has received prior SRS, retreatment with SRS may be considered medically necessary when ALL of the following conditions are met:
- (No lesion is greater than 5cm and all lesions may be treated in a single treatment plan in a single fraction (for SRS) or up to five (5) fractions (for fractionated SRS).
- The individual has not been treated with more than two (2) episodes of SRS in the past nine (9) months; and
- Note that ALL lesions present on imaging must be targeted as a single episode of care. If this cannot be accomplished in a maximum of five (5) fractions, each fraction must be billed as 3D conformal or IMRT, depending on the planning, as the definition of SRS is not met; and
- Life expectancy greater than six(6) months; and
- Submission of recent consultation note and recent restaging studies.
- In an individual who has received prior WBRT, SRS may be considered medically necessary if:
- Life expectancy greater than three (3) months.
- Post-operative SRS may be considered medically necessary for treatment of:
- A combination of four (4) resected and unresected lesions that are individually greater than four (4) centimeters in size.
| Place of Service: Outpatient |
Stereotactic Radiosurgery is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
05/2018, REMINDER: Radiation Therapy
01/2018, REMINDER: Radiation Therapy
 |
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
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If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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