Medical_Policy

Highmark Commercial Medical Policy - Pennsylvania

Medical Policy:	R-14-006
Topic:	Stereotactic Body Radiation Therapy (SBRT)
Section:	Radiation Therapy & Nuclear Medicine
Effective Date:	July 31, 2017
Issue Date:	July 31, 2017
Last Reviewed:	March 2017

Stereotactic body radiotherapy (SBRT) is a fractionated method of stereotactically guided radiation therapy applied over several days, typically to areas of the body other than cranial. SBRT utilizes 3-dimensional conformal radiotherapy method that delivers highly focused, convergent radiotherapy beams on a target that is defined with 3-dimensional imaging techniques with ability to spare adjacent radiosensitive structures. SBRT is used to treat small tumors in the chest, abdomen or tumors that cannot be removed surgically or treated with conventional radiotherapy due to the location.

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.

Stereotactic body radiation therapy (SBRT) with a radiation source (e.g. gamma knife, cyberknife, or high energy photons generated by a linear accelerator [LINAC] unit ) may be considered medically necessary for localized malignant conditions within the body where highly precise application of high-dose radiotherapy is required to avoid surrounding normal tissue exposure.

Stereotactic body radiation therapy (SBRT) may be considered medically necessary for non-small cell lung cancer when ALL of the following are met:

Primary T1 or T2 non-small cell lung cancer (single lesion not greater than 5 cm); and
No nodal or distant disease; and
Are not candidates for surgical resection.

SBRT is considered experimental/investigational for any other indications not stated above and therefore, non-covered. Scientific evidence does not support the safety and/or effectiveness of this service can be established by the available published peer-reviewed literature for any other indications.

Procedure Codes

32701, 77373, 77435, G0339, G0340

Stereotactic body radiation therapy (SBRT) may be considered medically necessary for primary localized tumors of the liver not amenable to surgery.

SBRT is considered experimental/investigational for any other indications not stated above and therefore is non-covered. Scientific evidence does not support the safety and/or effectiveness of this service can be established by the available published peer-reviewed literature for any other indications.

Procedure Codes

32701, 77373, 77435, G0339, G0340

Stereotactic body radiation therapy (SBRT) may be considered medically necessary for localized prostate cancer when ALL of the following are met:

Low grade prostate cancer defined by a Gleason score equal to 6 and prostate-specific antigen (PSA) less than 10 ng/mL; and
Minimal disease defined as less than four cores positive; and
No evidence of extra prostatic disease.

Procedure Codes

32701, 77373, 77435, G0339, G0340

Other Covered Indications

Stereotactic body radiation therapy (SBRT) may be considered medically necessary for:

If the tumor histology is germ cell or lymphoma, effective chemotherapy regimens have been exhausted or are otherwise not feasible; or
Lesions that have been treated previously with radiotherapy or are immediately adjacent to previously irradiated fields will be covered on an individual basis. This includes:
- Bony lesions of the spine that have failed external beam radiation; or
- Recurring or previously irradiated cancers of the spine and spinal cord (metastatic or primary); or
- Non-radiosensitive melanoma; or
Recurring or previously irradiated tumors of the head and neck with metastasis to other critical organs or structures.

Procedure Codes

32701, 77373, 77435, G0339, G0340

SBRT treatment management (code 77435) is eligible once per course of treatment with the entire course not to exceed five fractions, and includes the work of imaging guidance during treatment.

Procedure Codes

77435

FEP Guidelines

Refer to Medical Policy:

S-130 Cryosurgery of the Liver.
S-141 Radiofrequency Ablation (RFA) and Cyrosurgery of Primary or Metastatic Liver Tumors.
S-158 Cryosurgical Ablation and Radiofrequency Ablation of Renal Tumors.

Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree 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

05/2017, Revised Coverage for Stereotactic Body Radiation Therapy (SBRT)

Link to Diagnosis Codes

Link to References

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.

Discrimination is Against the Law
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:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

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.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.