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02-77371-02

Original Effective Date: 09/15/08

Reviewed: 09/28/17

Revised: 10/15/17

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Stereotactic Body Radiotherapy

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           

Position Statement

Billing/Coding

Reimbursement

Program Exceptions

Definitions

Related Guidelines

           

Other

References

Updates

   

Previous Version

           

DESCRIPTION:

Stereotactic body radiation therapy (SBRT) is an external beam radiation therapy used to deliver a high dose of radiation to extracranial target (s) within the body. Small fields and rigid fixation based on frame or imaging based stereotaxy are used to minimize exposure of the delivered radiation to the healthy tissue around the target. SBRT delivers highly focused convergent beams sparing adjacent structures. It may offer a non-invasive alternative to invasive surgery, particularly for patients unable undergo surgery or for lesions that are difficult to access surgically or are adjacent to vital organs.

The emerging trend in recent years has been toward shorter, more “hypofractionated” courses (radiation treatment that delivers more than one treatment session per day), such as with SBRT. SBRT may be given with a single session (fraction) or up to five fractions, referred to as fractionated stereotactic radiotherapy. Fractionation has been made possible by the ability to duplicate the treatment plan from one session to the next. Fractionation of stereotactic radiotherapy aims to optimize the therapeutic ratio; that is the ratio between tumor control and late effects on normal tissues. The main advantage of fractionation is that it allows higher total doses to be delivered to the tumor because of increased tolerance of the surrounding healthy tissues to each individual, fractionated dose.

SBRT can be applied using noninvasive or minimally invasive stereotactic localization and radiation delivery techniques. SBRT may be delivered by a number of commercially available devices (e.g., Accuray’s, Cyberknife®, Brain Lab’s Novallis®, Varian’s Trilogy®, Electra’s Synergy®). These devices may incorporate robotics and real-time imaging. SBRT devices (e.g., Accuray’s, Cyberknife®, Brain Lab’s Novallis®, Varian’s Trilogy®, Electra’s Synergy®) have received clearance for marketing by the U.S. Food and Drug Administration (FDA).

POSITION STATEMENT:

Note: For stereotactic radiosurgery, refer to Stereotactic Radiosurgery (Intracranial), 02-77371-01.

Note: For Fractionation and Radiation Therapy, refer to Fractionation and Radiation Therapy, 04-77260-25.

Stereotactic body radiotherapy performed with an FDA-approved device, meets the definition of medical necessity for the following indications:

Bone Metastases

• To treat a previously irradiated field; AND

• Re-treatment with EBRT would result in significant risk of spinal cord injury (e.g., cumulative spinal cord dose >50 Gy in 2 Gy equivalent).

Spine Lesions (primary or metastatic lesions of the spine)

Stereotactic body radiotherapy (SBRT) meets the definition of medical for spine lesions when EITHER of the following is met:

When other treatment options are not available (BOTH of the following must be met):

• Not amenable to surgical resection (AT LEAST ONE of the following must apply):

Related to prior surgery, tumor location, or surgical candidacy; OR

Surgery alone is not an option; AND

• When lesions are not amenable to 3D conformal techniques; OR

• To treat a previously irradiated field.

Colorectal and Anal Cancers

Anal Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for anal cancer when the following is met:

• To treat a previously irradiated field.

Rectal Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for rectal cancer when the following is met:

• To treat a previously irradiated field.

Colon Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for colon cancer when the following is met:

• To treat a previously irradiated field.

Gastrointestinal Cancers, Non-Colorectal (cholangioangiocarcinoma, esophageal, gastric, liver and pancreatic)

Cholangiocarcinoma

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for cholangiocarcinoma when the following is met:

• To treat a previously irradiated field.

Esophageal Cancer

Stereotactic body radiotherapy (SBRT) is appropriate for esophageal cancer when the following is met

• To treat a previously irradiated field.

Gastric Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for gastric cancer when the following is met:

• To treat a previously irradiated field.

Hodgkin and Non-Hodgkin Lymphoma

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for Hodgkin and non-Hodgkin lymphoma when the following condition is met:

To treat a previously irradiated field.

Liver Cancer

Hepatocellular carcinoma

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity when any of the following are met:

As palliative treatment for members with liver-related symptoms after other therapy options have been exhausted; OR

As treatment of up to 3 lesions, as an option to surgery or embolization when these therapies have been done and have failed, or are contraindicated, when ALL of the following conditions are met:

Diameter less than 6 cm; AND

Members with Child-Pugh category A or B; AND

(Note: SBRT has not been established as a safe treatment option in patients with Child-Pugh category C cirrhosis.)

Member has a good performance status (*ECOG performance status of 0-2, **Karnofsky Performance Scale 70% or greater); OR

• To treat a previously irradiated field.

*Eastern Cooperative Oncology Group (ECOG) Performance Status

**Karnofsky Performance Scale (KPS)

Liver Metastases

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for liver metastases when any of the following are met:

• As palliative treatment for members with liver-related symptoms

• Particularly after other therapy options have been exhausted; OR

• To treat a previously irradiated field.

Pancreatic Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for pancreatic cancer when the following is met:

• To treat a previously irradiated field.

Genitourinary (bladder, penile and testicular) Cancers

Bladder Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for bladder cancer when the following is met:

• To treat a previously irradiated field.

Penile Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for penile cancer when the following is met:

• To treat a previously irradiated field.

Testicular Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for testicular cancer when the following is met:

• To treat a previously irradiated field.

Gynecologic Cancers (cervical, fallopian tube, ovarian, uterine, and vulvar/vaginal)

Cervical Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for cervical cancer when the following is met:

• To treat a previously irradiated field.

Fallopian Tube Cancer

Stereotactic Body Radiotherapy (SBRT) meets the definition of medical necessity for fallopian tube cancer when the following is met:

• To treat a previously irradiated field.

Ovarian Cancer

Stereotactic Body Radiotherapy (SBRT) meets the definition of medical necessity for ovarian cancer when the following is met:

• To treat a previously irradiated field.

Uterine Neoplasms (endometrial carcinoma, uterine sarcoma, uterine carcinosarcoma)

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for uterine neoplasms when the following is met:

• To treat a previously irradiated field.

Vulvar/Vaginal Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for vulvar/vaginal cancer when the following is met:

• To treat a previously irradiated field.

Head and Neck Cancers (including thyroid cancer)

Head and Neck

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for head and neck cancer when the following is met:

• To treat a previously irradiated field.

Thyroid

Stereotactic Body Radiotherapy (SBRT) meets the definition of medical necessity for head and neck cancer when the following is met:

• To treat a previously irradiated field.

Lung Cancer (small cell and non-small cell)

Primary Lung Cancers

Non-Small Cell Lung Cancer

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for non-small cell lung cancer if any of the following are met:

For an alternative to surgical resection when (ALL of the following must apply)

Treatment intent is cure; AND

• There is no evidence of nodal or distant metastases based on conventional staging techniques (Stage IA, IB, or IIA with negative lymph nodes); AND

b. Single lesion measuring less than or equal to 5 cm; AND

c. Lesion is inoperable for ANY of the following reasons:

Tumor location; OR

Member is not a surgical candidate due to a medical contraindication; OR

• To treat a previously irradiated field.

Small Cell Lung Cancer

Stereotactic Body Radiotherapy (SBRT) meets the definition of medical necessity for small cell lung cancer when the following is met:

• To treat a previously irradiated field.

Metastatic Lesions in the Lung

Stereotactic body radiotherapy (SBRT) meets the definition of medical necessity for metastatic lesions in the lung when any of the following are met:

To treat a metastatic lesion (ALL of the following must be met)

Member with a single metastatic lesion measuring less than 5 cm; AND

• Oligometastatic disease may be considered on a case-by-case basis.

• Member has a good performance status (EITHER of the following must apply)

*ECOG performance status of 0, 1, or 2; OR

**Karnofsky Performance Scale greater than or equal to 70%; AND

Extrapulmonary disease is stable or volume of disease is low with remaining treatment options; AND

Intent is either:

Curative; OR

• Palliative, with a current symptom or anticipation of a symptom (for example, lesion is close to a major vessel and without local treatment, is anticipated to lead to hemoptysis or hemorrhage); OR

• To treat a previously irradiated field.

*Eastern Cooperative Oncology Group (ECOG) Performance Status

**Karnofsky Performance Scale (KPS)

Other Tumor Types (including other malignancies)

Other Malignancies

Stereotactic Body Radiotherapy (SBRT) meets the definition of medical necessity for other malignancies when the following is met:

• To treat a previously irradiated field.

Prostate Cancer

Stereotactic body radiotherapy performed with an FDA-approved device, meets the definition of medical necessity for clinically localized prostate cancer when ALL of the following criteria are met:

• Stage less than T3a; AND

• Gleason score less than 8; AND

• PSA less than 20; AND

• Negative bone scan.

Local Recurrence

Stereotactic body radiotherapy meets the definition of medical necessity for local recurrence for prostate cancer when the following is met:

• Only to treat a previously irradiated field.

Stereotactic body radiotherapy for ALL other indications is considered experimental or investigational due to the lack of scientific evidence to support the effect on health outcomes.

BILLING/CODING INFORMATION:

Note: Procedure and diagnoses codes may not be all inclusive.

CPT Coding:

32701

Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment

63620

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion

63621

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)

77280

Therapeutic radiology simulation-aided field setting; simple

77285

Therapeutic radiology simulation-aided field setting; intermediate

77290

Therapeutic radiology simulation-aided field setting; complex

77295

3-dimensional radiotherapy plan, including dose-volume histograms

77373

Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

77402

Radiation treatment delivery, >1 MeV; simple

77407

Radiation treatment delivery, >1 MeV; intermediate

77412

Radiation treatment delivery, >1 MeV; complex

77435

Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions

HCPCS Coding:

G0251

Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum five sessions per course of treatment

G0339

Image guided robotic linear accelerator base stereotactic radiosurgery, complete course of therapy in one session, or first session of fractionated treatment

G0340

Image guided robotic linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five session per course of treatment

ICD-10 Diagnosis Codes That Support Medical Necessity:

C00.0 – C00.9

Malignant neoplasm of lip

C01

Malignant neoplasm of base of tongue

C02.0.C02.9

Malignant neoplasm of other and unspecified parts of tongue

C03.0 – C03.9

Malignant neoplasm of gum

C04.0 – C04.9

Malignant neoplasm of floor of mouth

C06.0 – C06.2

Malignant neoplasm of other and unspecified parts of mouth

C06.80 – C06.89

Malignant neoplasm of overlapping sites of other and unspecified parts of mouth

C06.9

Malignant neoplasm of mouth, unspecified

C07

Malignant neoplasm of parotid gland

C08.0 – C08.9

Malignant neoplasm of other and unspecified major salivary glands

C09.0 – C09.9

Malignant neoplasm of tonsil

C10.0 – C10.9

Malignant neoplasm of oropharynx

C11.0 – C11.9

Malignant neoplasm of nasopharynx

C13.0 – C13.9

Malignant neoplasm of hypopharynx

C14.0 – C14.8

Malignant neoplasm of other and ill-defined sites in the lip, oral cavity and pharynx

C15.3 – C15.9

Malignant neoplasm of esophagus

C16.0 – C16.9

Malignant neoplasm of stomach

C18.0 – C18.9

Malignant neoplasm of colon

C19

Malignant neoplasm of rectosigmoid junction

C20

Malignant neoplasm of rectum

C21.0 – C21.8

Malignant neoplasm of anus and anal canal

C22.0 – C22.9

Malignant neoplasm of liver and intrahepatic bile ducts

C25.0 – C25.9

Malignant neoplasm of pancreas

C30.0, C30.1

Malignant neoplasm of nasal cavity and middle ear

C31.0 – C31.9

Malignant neoplasm of accessory sinuses

C32.0 – C32.9

Malignant neoplasm of larynx

C34.00 – C34.02
C34.10 – C34.12
C34.2
C34.30 – C34.32
C34.80 – C34.82
C34.90 – C34.92

Malignant neoplasm of bronchus and lung

C41.2

Malignant neoplasm of vertebral Column

C50.0

Malignant neoplasm of nipple and areola

C51.0 – C51.9

Malignant neoplasm of vulva

C52

Malignant neoplasm of vagina

C53.0 – C53.9

Malignant neoplasm of cervix uteri

C54.0 – C54.9

Malignant neoplasm of corpus uteri

C55

Malignant neoplasm of uterus, part unspecified

C56.1 – C56.9

Malignant neoplasm of ovary

C57.00 – C57.02

Malignant neoplasm of fallopian tube

C60.0 – C60.9

Malignant neoplasm of penis

C61

Malignant neoplasm of prostate

C62.00 – C62.02
C62.10 – C62.12
C62.90 – C62.92

Malignant neoplasm of testis

C67.0 – C67.9

Malignant neoplasm of bladder

C69.30 – C69.32

Malignant neoplasm of choroid

C71.0 – C71.9

Malignant neoplasm of brain

C73

Malignant neoplasm of thyroid gland

C76.0

Malignant neoplasm of head, face and neck

C78.00 – C78.02

Secondary malignant neoplasm of lung

C78.7

Secondary malignant neoplasm of liver and intrahepatic bile duct

C79.51 – C79.52

Secondary malignant neoplasm of bone and bone marrow

C79.31 – C79.32

Secondary malignant neoplasm of brain and cerebral meninges

C79.40 – C79.49

Secondary malignant neoplasm of other and unspecified parts of nervous system

C79.82

Secondary malignant neoplasm of genital organs

C80.1

Malignant (primary) neoplasm, unspecified

D02.20-D02.22

Carcinoma in situ of bronchus and lung

D33.0 – D33.2

Benign neoplasm of brain

D35.2

Benign neoplasm of pituitary gland

D35.4

Benign neoplasm of pineal gland

G50.0

Trigeminal neuralgia

Q28.2

Arteriovenous malformation of cerebral vessels

Z08

Encounter for follow-up examination after completed treatment for malignant neoplasm

Z51.0

Encounter for antineoplastic radiation therapy

Z51.5

Encounter for palliative care

Z53.09

Procedure and treatment not carried out because of other contraindication

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for stereotactic body radiotherapy.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Note: Coverage for stereotactic body radiotherapy (SBRT) performed and billed in an outpatient or office location will be handled through the Radiation Oncology program for select products. AIM Specialty Health will determine coverage for stereotactic body radiotherapy (SBRT) for select products. Refer to member's contract benefits.

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline review date: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT), ( L33410) located at fcso.com.

DEFINITIONS:

Fraction: a single session of radiation treatment delivered to a specific area of interest at one setting.

Fractionation: the schedule of fractions of treatment as it is delivered. This is usually expressed as the number of fractions or treatment sessions delivered over a specific period of time.

Radioresistant: resistance to irradiation (radiation therapy, radiotherapy).

RELATED GUIDELINES:

Stereotactic Radiosurgery (Intracranial), 02-77371-01
Fractionation and Radiation Therapy, 04-77260-25

OTHER:

Other names used to report stereotactic body radiotherapy:

Stereotactic Ablative Radiotherapy (SABR)

Functional Status Tools

The Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) is used to quantify the functional status of cancer patients and is a factor in determining prognosis in a number of malignant conditions. The PS describes the status of symptoms and functions with respect to ambulatory status and need for care. PS 0 means normal activity, PS 1 means some symptoms, but still near fully ambulatory, PS 2 means less than 50%, and PS 3 means more than 50% of daytime in bed, while PS 4 means completely bedridden.

Eastern Cooperative Oncology Group (ECOG) Performance Status

Performance Status (PS) Score

ECOG

0

Fully active, able to carry on all predisease performance without restriction

1

Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (e.g., light house work, office work)

2

Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours

3

Capable of only limited self-care, confined to bed or chair more than 50% of waking hours

4

Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair

5

Dead

Adapted from: Blagden SP, Charman SC, Sharples LD et al 2003. Performance status score: do patients and their oncologists agree? British Journal of Cancer 2003; 89(6): 1022-1027

The Karnofsky Performance Scale (KPS) allows patients to be classified as to their functional impairment. The scale relates to physical ability and covers 11 stages, ranging from normal health to death, with each stage scored as a percentage. A score between 0 and 100 is assigned by a healthcare professional after observing a patient perform a tasks and/or activity of daily living. A score of 100% means that the patient has normal physical abilities with no signs of disease, decreasing percentage means that the patient has less ability to perform activities of daily living. The Karnofsky Performance Scale can be used to compare effectiveness of different therapies and to assess patient’s prognosis.

Karnofsky Performance Scale (KPS)

General Category

%

Criteria

• Able to carry on normal activity and work

• No special care needed

100

Normal no complaints; no evidence of disease.

90

Able to carry on normal activity; minor signs or symptoms of disease.

80

Normal activity with effort; some signs or symptoms of disease.

• Unable to work

• Able to live at home and care for most personal needs

• Varying amount of assistance needed

70

Cares for self; unable to carry on normal activity or to do active work.

60

Requires occasional assistance, but is able to care for most of his personal needs.

50

Requires considerable assistance and frequent medical care.

• Unable to care for self

• Requires equivalent of institutional or hospital care

• Disease may be progressing rapidly

40

Disabled; requires special care and assistance.

30

Severely disabled; hospital admission is indicated although death not imminent.

20

Very sick; hospital admission necessary; active supportive treatment necessary.

• Terminal state

10

Moribund

 

0

Dead

Adapted from: Crooks V, Waller S, Smith T et al. The Use of the Karnofsky Performance Scale in Determining Outcomes and Risk in Geriatric Outpatients. The Journals of Gerontology 1991 Jul; 46(4): M139-M144

REFERENCES:

  1. AIM Specialty Health Clinical Appropriateness Guidelines: Radiation Oncology Bone Metastases, Breast Cancer, Central Nervous System Cancers, Colorectal and Anal Cancers, Gastrointestinal Cancers and Non-Colorectal, Genitourinary (Penile and Testicular) Cancers, Gynecologic Cancers, Head and Neck Cancers, Lung Cancer (Small Cell and Non-Small Cell), Other Tumor Types (including Sarcoma, Thymoma and thymic carcinoma, Pediatric Tumors and Other Malignancies) and Prostate Cancer, 09/17.
  2. Aluwini S, van Rooij P, Hoogeman M et al. Cyberknife stereotactic radiotherapy as monotherapy for low-to intermediate-stage prostate cancer: early experience, feasibility, and tolerance. Journal of Endourology 2010; 24(5): 865-869.
  3. Alongi F, Arcangeli S, Filippi AR et al. Review and uses of stereotactic body radiation therapy for oligometastases. Oncologist 2012; 17(8): 1100-1107.
  4. Benzil DL, Saboori M, Mogilner AY, Rocchio R, Moorthy CR. Safety and efficacy of stereotactic radiosurgery for tumors of the spine. J Neurosurg. 2004 ; 101 Suppl 3: 413 – 8.
  5. Bhattasali O, Chen LN, Woo J et al. Patient-reported outcomes following stereotactic body radiation therapy for clinically localized prostate cancer. Radiation Oncology 2014; 9:52.
  6. Boike TP, Lotan Y, Cho LC et al. Phase I dose-escalation study of stereotactic body radiation therapy for low-and intermediate-risk prostate cancer. Journal of Clinical Oncology 2011; 29(15): 2020-2026.
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  17. Cupp JS, Koong AC, Fisher GA et al. Tissue effects after stereotactic body radiotherapy using cyberknife for patients with abdominal malignancies. Clinical Oncology (Royal College Radiologists) 2008; 20(1): 69-75.
  18. Degen JW, Gagnon GJ, Voyadzis JM, McRae DA, Lunsden M, Dieterich S, Molzahn I, Henderson FC. CyberKnife stereotactic radiosurgical treatment of spinal tumors for pain control and quality of life. J Neurosurg Spine. 2005; 2 (5): 540-9.
  19. Dodd RL, Ryu MR, Kamnerdsupaphon P, Gibbs IC, Chang SD Jr, Adler JR Jr. CyberKnife radiosurgery for benign intradural extramedullary spinal tumors. Neurosurgery. 2006 Apr; 58 (4):674-85; discussion 674-85.
  20. Finn MA, Vrionis FD, Schmidt MH. Spinal radiosurgery for metastatic disease of the spine. Cancer Control. 2007 ; 14 (4): 405 – 11.
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  22. Friedland JL, Freeman DE, Masterson-McGary ME et al. Stereotactic body radiotherapy: an emerging treatment approach for localized prostate cancer. Technology in Cancer Research and Treatment 2009; 8(3): 387-392.
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/28/17.

GUIDELINE UPDATE INFORMATION:

09/15/08

New Medical Coverage Guideline.

01/01/09

Annual HCPCS coding update: added codes 63620 and 63621.

11/15/09

Annual review. Maintain position statements. Add program exception for Medicare. Updated references.

06/15/10

Annual review. Updated description. Added G0251. Updated Medicare Advantage program exception; added indications for cranial lesions and ICD-9 codes that support medical necessity. Deleted related Internet link. Updated references.

05/15/11

Updated Medicare program exception.

01/01/13

Annual HCPCS coding update; added 32701.

07/15/14

Annual review; updated description, added spinal or vertebral body tumors (metastatic or primary) in members who have received prior radiation therapy, added spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma, sarcoma), added stereotactic body radiation therapy performed using fractionation for the above indications meets the definition of medical necessity, updated Medicare Advantage products program exceptions, and updated references.

07/15/15

Annual review. Added position statement for clinically localized prostate cancer. Updated reference.

05/01/16

Revision; added/revised indications: bone metastases, breast cancer, CNS cancers, intracranial lesions, medulloblastoma, supratentorial, PNET, ependymoma, CNS lymphoma, metastatic brain lesions, benign brain lesions, pituitary adenomas, meningioma, other benign brain tumors (acoustic neuromas, carniopharyngiomas, pineal gland tumors, schwannomas), ocular lesions, retinoblastoma, spine lesions (primary or metastatic), other neurologic indication (trigeminal neuralgia), colorectal and anal cancers, gastrointestinal cancers, non-colorectal (cholangiocarcinoma, esophageal, gastric, liver and pancreatic), genitourinary cancers (bladder, penile and testicular), gynecologic cancers (cervical, fallopian tube, ovarian, uterine, and vulvar/vaginal), head and neck cancers (including thyroid cancer), lung cancer (small cell and non-small cell), other tumor types (including other malignancies), and prostate cancer; added code 77280, 72285, 77290, 77295, 77338, 77402, 77407 and 77412; added ICD-10 codes; added LOINC codes; updated program exception; updated references.

08/15/16

Updated program exceptions.

11/15/16

Revision; revised position statement. Updated references.

01/01/17

Annual HCPCS code update. Revised 77402, 77407 and 77412 code descriptor.

10/15/17

Revision; revised position statement. Added Hodgkin and Non-Hodgkin lymphoma. Updated references.

Date Printed: October 23, 2017: 02:14 AM