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Date Printed: August 18, 2017: 07:57 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-77371-01

Original Effective Date: 09/15/08

Reviewed: 10/19/16

Revised: 04/15/17

Subject: Stereotactic Radiosurgery (Intracranial)

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    
           

DESCRIPTION:

Stereotactic radiosurgery (SRS) is a method of delivering high doses of ionizing radiation to small intracranial targets. The technique differs from conventional radiotherapy, which involves exposing large areas of intracranial tissue to relatively broad fields of radiation over a number of sessions. SRS delivers highly focused convergent beams sparing adjacent structures. SRS may offer a non-invasive alternative to invasive surgery, particularly for individuals that are unable to undergo surgery or for lesions that are difficult to access surgically or for lesions that are adjacent to vital organs.

Several methods of this technology exist: gamma-ray radiosurgery (Gamma Knife®), linear-accelerator radiosurgery (LINAC), proton-beam radiosurgery, helium-ion radiosurgery, and neutron-beam radiosurgery. The latter 3 energy sources are collectively referred to as charged particles.

The Gamma Knife and linear accelerator systems are similar in concept; both use multiple photon radiation arcs that intersect at a stereotactically determined target, thus permitting higher doses of radiation delivery with sparing of surrounding normal tissues. The differences between them relate to how the energy is produced (i.e., through decaying cobalt or from x-rays) and the number of energy sources used (i.e., multiple energy sources in the gamma knife versus one in the linear accelerator system). Charged particles beams are fundamentally different in that they take advantage of the Bragg peak (i.e., the deposition of energy at a specific depth with minimal scatter). Typically, 3 to 5 fixed beams are used, similar to the beam arrangement in conventional radiotherapy.

The most common applications of SRS include treatment of intracranial malignancies, including primary and metastatic tumors, arteriovenous malformations (AVMs), acoustic neuromas (vestibular schwannomas), and other benign intracranial tumors such as meningiomas or pituitary adenomas.

POSITION STATEMENT:

Note: For Stereotactic Body Radiotherapy, refer to Stereotactic Body Radiotherapy, 02-77371-02.

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

Bone Metastases

• To treat a previously irradiated field

• 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)

Central Nervous System (CNS) Cancers (intracranial, spinal, ocular and neurologic)

Intracranial Lesions

Primary Malignant Brain Lesions

High Grade Gliomas (grade 3-4)

Stereotactic radiosurgery (SRS) for high grade gliomas meets the definition of medical necessity in members with good performance status (based on either of the following):

Recurrent disease; OR

To treat a previously irradiated field

Low Grade Gliomas (grade 1-2)

Stereotactic radiosurgery (SRS) meets the definition of medical necessity for low grade gliomas in members with good performance status (based on either of the following)

• ECOG 0, 1, or 2; OR

• Karnofsky Scale greater than or equal to 70%; AND

When one of the following is met:

• Initial treatment; OR

• Recurrent disease; OR

• To treat a previously irradiated field

Medulloblastoma, supratentorial primitive neuroectodermal tumors (PNET), Ependymoma

Stereotactic radiosurgery (SRS) for medulloblastoma, supratentorial PNET, ependymoma meets the definition of medical necessity when the following is met:

• To treat a previously irradiated field

CNS lymphoma

Stereotactic radiosurgery (SRS) for CNS lymphoma meets the definition of medical necessity when the following is met:

• To treat a previously irradiated field

Metastatic Brain Lesions

Stereotactic radiosurgery (SRS) for metastatic brain lesions meets the definition of medical necessity when ANY of the following are met:

• For members with good performance status ( based on wither of the following):

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

• **KPS Performance Scale greater than or equal to 70%

 *Eastern Cooperative Oncology Group (ECOG) Performance Status

**Karnofsky Performance Scale (KPS)

• To treat a previously irradiated field

Benign Brain Lesions

Intracranial arteriovenous malformations (AVMs)

Stereotactic radiosurgery (SRS) for AVMs meets the definition of medical necessity when the following is met:

• For treatment of intracranial arteriovenous malformations

Pituitary adenomas

Stereotactic radiosurgery (SRS) for pituitary adenomas meets the definition of medical necessity when any of the following conditions are met:

When member is symptomatic from endocrine abnormalities such as Cushing’s disease or acromegaly; OR

• To treat a previously irradiated field

Meningioma

Stereotactic radiosurgery (SRS) for meningioma meets the definition of medical necessity when any of the following conditions are met:

When lesion is unresectable or recurrent, or if there is residual disease following surgery; OR

• To treat a previously irradiated field

Other benign brain tumors (acoustic neuromas, craniopharyngiomas, pineal gland tumors, schwannomas)

Stereotactic radiosurgery (SRS) for other benign brain tumors meets the definition of medical necessity when the following is met:

• For treatment of other benign brain tumors, including: acoustic neuromas, craniopharyngiomas, pineal gland tumors, schwannomas

Glomus Jugulare Tumors

Stereotactic radiosurgery (SRS) for glomus jugulare tumors meets the definition of medical necessity.

Ocular Lesions

Uveal Melanoma

Stereotactic radiosurgery (SRS) for uveal melanoma meets the definition of medical necessity when any of the following conditions are met:

For treatment of melanoma of the choroid; OR

• To treat a previously irradiated field

Other Neurologic Conditions (trigeminal Neuralgia)

Stereotactic radiosurgery (SRS) for trigeminal neuralgia meets the definition of medical necessity when any of the following conditions are met:

When symptoms are refractory to standard medical management; OR

• To treat a previously irradiated field

Other Tumor Types (including sarcomas and pediatrics)

Sarcoma

Stereotactic radiosurgery (SRS) for sarcoma meets the definition of medical necessity when the following is met:

• To treat a previously irradiated field

Pediatrics

Stereotactic radiosurgery (SRS) for pediatric members (below age 18) meets the definition of medical necessity when any of the following are met:

To treat an intracranial malignancy; OR

• To treat a previously irradiated field

BILLING/CODING INFORMATION:

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

CPT Coding:

20660

Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)

61796

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

61797

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

61798

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

61799

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

61800

Application of stereotactic headframe for stereotactic radiosurgery (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

77371

Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cerebral lesion(s) consisting of 1 session; multi-source Cobalt 60 based

77372

Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cerebral lesion(s) consisting of 1 session; linear accelerator based

77402

Radiation treatment delivery, >1 MeV; simple

77407

Radiation treatment delivery, >1 MeV; intermediate

77412

Radiation treatment delivery, >1 MeV; complex

77432

Stereotactic radiation treatment management of cerebral lesion(s) (complete course of treatment consisting of one session)

HCPCS Coding:

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 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

C41.2

Malignant neoplasm of vertebral column

C50.0

Malignant neoplasm of nipple and areola

C69.30 – C69.32

Malignant neoplasm of choroid

C71.0 – C71.9

Malignant neoplasm of brain

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

D33.0 – D33.2

Benign neoplasm of brain and other parts of central nervous system

D35.2

Benign neoplasm of pituitary gland

D35.4

Benign neoplasm of pineal gland

Q28.2

Arteriovenous malformation of cerebral vessels

Z08

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

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 radiosurgery .

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 radiosurgery (SRS) 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 radiosurgery (SRS) 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:

Acoustic neuromas: a benign tumor that develops on the nerve that connects the ear to the brain.

Arteriovenous malformations (AVM): AVMs are defects in the vascular system. An AVM is a snarled tangle of arteries and veins that are connected to each other with no capillaries. An AVM interferes with the blood circulation in an organ and can happen anywhere, but they are more common in the brain or spinal cord.

Craniopharyngiomas: a benign tumor that develops near the pituitary gland.

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.

Glioma: a tumor of the brain that originates in a glial (supportive cell) in the brain or spinal cord.

Glomus jugulare tumor: a tumor of a part of the temporal bone in the skull. This tumor can affect the ear, upper neck, base of the skull, and the surrounding blood vessels and nerves.

Linear accelerator: a sophisticated machine used for a type of radiation therapy that delivers external beam radiotherapy.

Meningioma: a tumor that arises from the meninges (the membranes that surround the brain and spinal cord).

Pituitary adenoma: benign tumor of the pituitary gland (the master gland that controls other hormone producing glands of the body and influences numerous body functions including growth).

Trigeminal neuralgia: nerve disorder that stimulates the fifth cranial nerve in the face, causing episodic intense, stabbing, electric shock-like pain where the branches of the nerve are distributed to the lips, eyes, nose, scalp, forehead, upper and lower jaws; also known as tic douloureux.

RELATED GUIDELINES:

Proton Beam Therapy, 04-77260-18
Stereotactic Body Radiotherapy, 02-77371-02

Fractionation and Radiation Therapy, 04-77260-25

OTHER:

Other names used to report Robotic-assisted stereotactic surgery or radiosurgery:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

CyberKnife® Image-Guided Radiosurgery System

Frameless NeuroMate™ Stereotactic System

Mehrkoordinaten Manipulator (MKM) system

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 (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. ACR-ASTRO Practice Guideline for the Performance of Stereotactic Radiosurgery, 2014.
  2. 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 Sarcomas, Pediatrics and Other Malignancies) and Prostate Cancer, 2016.
  3. Ammirati M, Cobbs CS, Linskey ME et al. The role of retreatment in the management of recurrent/progressive brain metastases: a systematic review and evidence-based clinical practice guideline. Journal of Neuro-Oncology 2010; 96(1): 85-96.
  4. Aoyama H, Shirato H, Tago M, Nakagawa K, Toyoda T, Hatano K, Kenjyo M, Oya N, Hirota S, Shioura H, Kunieda E, Inomata T, Hayakawa K, Katoh N, Kobashi G. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA2006 Jun 7; 295(21): 2483-91.
  5. 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.
  6. Bowden G, Kano H, Tonetti D, et al. Stereotactic radiosurgery for arteriovenous malformations of the cerebellum. Journal of Neurosurgery 2014;120(3):583-590.
  7. Chang EL, Wefel JS, Hess KR et al. Neurocognition in patients with brain metastases treated with radiosurgery or radiosurgery plus whole-brain irradiation: a randomized controlled trial. Lance Oncology 2009; 10(11): 1037-1044.
  8. Combs SE, Thilmann C, Huber PE et al. Achievement of long-term local control in patients with craniopharyngiomas using high precision stereotactic radiotherapy. Cancer 2007; 109(11):2308-2314.
  9. 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; 46(4): M139-M144.
  10. DeVita: Cancer: Principles and Practice of Oncology, 5th ed., Lippincott-Raven Publishers; Chapter 67 – Fractionated (Relocatable) Stereotactic Radiotherapy, (1997).
  11. First Coast Service Options, Inc. Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT), L33410. 10/01/2015.
  12. Friehs GM, Park MC, Goldman et al. Stereotactic radiosurgery for functional disorders. Neurosurgical Focus 2007; 23(6): E3.
  13. Fuentes R, Bonfill X, Exposito J. Surgery versus radiosurgery for patients with a solitary brain metastasis from non-small cell lung cancer. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004840. DOI: 10.1002/14651858.CD004840.pub2.
  14. Hanson PW, Elaimy AL, Lamoreaux WT et al. A concise review of the efficacy of stereotactic radiosurgery in the management of melanoma and renal cell carcinoma brain metastases. World Journal of Surgical Oncology 2012; 10:176.
  15. Hasegawa T, Fujitani S, Katsumata S, Kida Y, Yoshimoto M, Koike J. Stereotactic radiosurgery for vestibular schwannomas: analysis of 317 patients followed more than 5 years. Neurosurgery. 2005 Aug; 57(2): 257-65; discussion 257-65.
  16. Kano H, Kondziolka D, Flickinger JC et al. Stereotactic radiosurgery for arteriovenous malformations, Part 6: multistaged volumetric management of large arteriovenous malformations. Journal of Neurosurgery 2012; 116(1):54-65.
  17. Hazard LJ, Jensen RL, Shrieve DC. Role of stereotactic radiosurgery in the treatment of brain metastases. Am J Clin Oncol. 2005 Aug; 28(4): 403-10.
  18. Jang RW, Caraiscos VB, Swami N et al. Simple prognostic model for patients with advanced cancer based on performance status. Journal of Oncology Practice 2014; 10(5): e335-e341.
  19. Jawahar A, Shaya M, Campbell P, Ampil F, Willis BK, Smith D, Nanda A. Role of stereotactic radiosurgery as a primary treatment option in the management of newly diagnosed multiple (3-6) intracranial metastases. Surg Neurol. 2005 Sep; 64(3): 207-12.
  20. Linskey ME, Andrews DW, Asher AL et al. The role of stereotactic radiosurgery in the management of patients with newly diagnosed brain metastases: a systematic review and evidenced-based clinical practice guideline. Journal of Neurosugery 2010; 96(1): 45-68.
  21. Mahajan A, McCutcheon IE, Suki D, Chang EL, Hassenbusch SJ, Weinberg JS, Shiu A, Maor MH, Woo SY. Case-control study of stereotactic radiosurgery for recurrent glioblastoma multiforme. J Neurosurg. 2005 Aug; 103(2): 210-7.
  22. Schag CC, Heinrich RL, Ganz PA. Karnofsky performance status revisited: reliability, validity, and guidelines. Journal of Clinical Oncology 1984; 2(3): 187-193.
  23. Sorensen JB, Klee M, Palshof T et al. Performance status assessment in cancer patients. An inter-observer variability study. British Journal of Cancer 1993; 67(4): 773-775.
  24. Suh JH. Stereotactic radiosurgery for the management of brain metastases. New England Journal of Medicine 2010; 362(12): 1119-1127.
  25. Ulm AJ 3rd, Friedman WA, Bradshaw P, Foote KD, Bova FJ. Radiosurgery in the treatment of malignant gliomas: the University of Florida experience. Neurosurgery. 2005 Sep; 57(3): 512-7; discussion 512-7.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/19/16.

GUIDELINE UPDATE INFORMATION:

09/15/08

Review and revision of guideline consisting of updated references: Changed MCG name from Stereotactic Radiosurgery to Stereotactic Body Radiotherapy to Stereotactic Radiosurgery (Intracranial) Changed MCG # from 02-61000-25 to 02-77371-01. Removed information about stereotactic body radiotherapy and created new MCG 02-77371-02 Stereotactic Body Radiotherapy.

01/01/09

Annual HCPCS coding update: added codes 61796, 61797, 61798 and 61799. Deleted code 61793.

11/15/09

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

11/15/10

Annual review: position statements maintained, added ICD-1 codes, reformatted Medicare Advantage program exceptions, added ICD-10 web link for Medicare, and updated references.

10/01/11

Revision; formatting changes.

11/15/11

Annual review; maintain position statements. Updated references.

11/15/12

Annual review; added craniopharyngiomas (237.0), glomus jugulare tumors (237.3) and stereotactic radiosurgery performed with fractionation, revised experimental or investigational statement, added 77435 and updated references.

01/01/13

Coding clarification.

05/15/14

Scheduled review; position statement maintained. Updated description section, deleted diagnosis code 742.9 (and ICD-10 Q04.9 and Q07.9), updated Medicare Advantage products program exceptions, definitions, references and decision tree.

05/15/15

Scheduled review. Updated description and references. Revised indication solitary or multiple brain metastases; add primary and metastatic. Revised wording: stereotactic radiosurgery performed for all other indications; delete “the lack of”, replace with “insufficient”.

05/01/16

Revision; added/revised indications: bone metastases, central nervous system cancers (intracranial, spinal, ocular and neurologic), other neurologic conditions (trigeminal neuralgia), other tumor types (including sarcomas, pediatrics and other malignancies, and sarcoma); deleted 77435; added 77280, 72285, 77290, 77295, 77338, 77402, 77407 and 77412; added ICD-10 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.

04/15/17

Code udate; deleted G0173 and G0251.

Date Printed: August 18, 2017: 07:57 PM