Stereotactic radiosurgery (SRS) is 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, 225.4)
• 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, 198.3)
• primary malignancies of the central nervous system, such as high-grade gliomas (initial treatment or treatment of recurrence), vestibular schwannomas, chordomas, chondrosarcomas, oligodendrogliomas (170.9, 171.0, 192.0-192.9)
• craniopharyngiomas (194.3, 227.3)
• neoplasms of the pineal gland (194.4, 227.4)
• nasopharyngeal or paranasal sinus malignancies (147.0-147.9, 160.0-160.9)
• hemangiomas (228.00, 228.02)
• trigeminal neuralgia refractory to medical management (350.1)

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 uses externally generated ionizing radiation in select cases 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 head frame affixed to a patient, a system of implanted fiducials or markers, or a similar system. This type of localization allows the physician to perform stereotactic procedures with a high degree of anatomic accuracy and precision.  In addition, this method of highly-focused energy irradiation spares adjacent or surrounding healthy tissue and/or organs. SRS can be performed using various FDA-approved devices that deliver the radiation stereotactically. The more commonly used systems include the Gamma Knife System which uses gamma rays, or linear accelerators (LINACs). Common brand names for various linear accelerators available include the X-Knife, Peacock System, Clinac, Trilogy, Synergy, and CyberKnife.   

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” form of stereotactic radiation therapy. This technique is made possible by the availability of noninvasive repositioning devices that can be used in lieu of a fixed head frame. Stereotactic radiotherapy is 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 dose planning software, neurodiagnostic imaging and guidance procedures, and the use of robotics have contributed to the new “frameless” stereotactic methods 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 that collectively describe "stereotactic" 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. An example of this technology is the FDA-approved CyberKnife. This device consists of a lightweight linear accelerator (LINAC) mounted on a six-axis robotic manipulator that permits a wide range of beam orientations. It uses 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 procedure 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.

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

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

MPRM 6.01.10