LCD/NCD Portal

L30364

 

STEREOTACTIC RADIOSURGERY (SRS) AND STEREOTACTIC BODY RADIATION THERAPY (SBRT)

 

11/29/2012

 

Indications and Limitations of Coverage and/or Medical Necessity

 

This LCD recognizes these two distinct treatment approaches and is specific to treatment delivery:

 

Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT): cranial lesions are distinct disciplines that utilize externally generated high dose ionizing radiation in certain cases to inactivate or eradicate (a) defined target (s) in the head without the need to make an incision.

o The target is defined by high-resolution stereotactic imaging.

o The process of care involves the radiation oncologist and/or neurosurgeon and physicist. For a subset of tumors involving the skull base, the multidisciplinary team may also include a head and neck surgeon with training in stereotactic radiosurgery.

o SRS/SBRT are typically performed in a single session, using a rigidly attached stereotactic guiding device, other immobilization technology and/or a stereotactic image-guidance system, but can be performed in a limited number of sessions, up to a maximum of five.

• Technologies that are used to perform SRS/SBRT include linear accelerators, particle beam accelerators, and multi-source Cobalt 60 units.

o In order to enhance precision, various devices may incorporate robotics and real time imaging.

• To qualify for SRS/SBRT a high dose should be delivered in a single fraction or in 2-5 fractions. 500 cGy (5 Gray) in a single dose is considered the minimum dose as a ‘high dose’ for SRS.

o A more typical dose would be 1400-2500 cGy (14-25 Gray) if given in one fraction.

• In general, SRS/SBRT is not indicated for cancers that are widely disseminated, unless evidence can be provided to justify the expectation of a meaningful clinical benefit, as well as evidence of a dosimetric advantage for SRS/SBRT over other forms of radiation therapy.

 

Indications

• SRS/SBRT: cranial lesions will be considered medically reasonable and necessary for the following indications:

o Primary central nervous system malignancies, generally under 5 cm and as a boost treatment for larger cranial, base of skull, or spinal lesions that have been treated initially with external beam radiation therapy or surgery:

 Grade III and IV gliomas.

 Oligodendrogliomas.

 Sarcomas.

 Chondrosarcomas.

 Chordomas.

 Nasopharyngeal or paranasal sinus malignancies).

o Primary and secondary tumors involving:

 Brain or spine parenchyma.

 Meninges/dura.

 Immediately adjacent boney structures.

o Benign brain tumors and spinal tumors:

 Cranial meningiomas.

 Acoustic neuromas.

 Other schwanomas.

 Pituitary adenomas.

 Pineal cytomas.

 Craniopharyngiomas.

 Glomus tumors.

 Hemangiolastomas.

o Cranial arteriovenous malformations and hemangiomas.

o Trigeminal neuralgia not responsive to medical management.

o Metastatic brain lesions, generally limited in number, with stable systemic disease, Karnofsky

o Performance Status 40 or greater (or expected to return to 70 or greater with treatment), and otherwise reasonable survival expectations or an Eastern Cooperative Oncology Group (ECOG):

 Performance Status of 3 or less (or expected to return to 2 or less with treatment).

 Relapse in a previously irradiated cranial or spinal field where the additional stereotactic precision is required to avoid unacceptable vital tissue radiation.

 Other cranial non-neoplastic conditions for which it has been proven effective

• Movement disorders such as Parkinson’s disease.

• Essential tremor and other disabling tremor that are refractory to conventional therapy, such as severe, sustained trigeminal neuralgia not responsive to other modalities.

 

• Stereotactic Body Radiation Therapy (SBRT) is an emerging treatment method that utilizes externally generated high dose ionizing radiation in certain cases to inactivate or eradicate (a) defined target (s) within the body.

• The target is defined by high-resolution stereotactic imaging.

o In addition to the radiation oncologist and/or neurosurgeon and physicist, the process may involve input from other surgical specialists.

o SBRT performed using immobilization technology and a stereotactic image-guidance system can be performed in a limited number of sessions, up to a maximum of five.

• To qualify for SBRT, a high dose should be delivered in a single fraction or in 2-5 fractions. 500 cGy (5 Gray) is considered the minimum dose as a ‘high dose’ for SBRT.

o A more typical dose would be 1400-2500 cGY (14-25 Gray) if given in one fraction.

 

Indications

• SBRT will be considered medically reasonable and necessary for certain conditions as long as the following criteria are met:

o Either #1, #2, or #3 must be present.

And

o Either #4 or #5 must be present.

And

o #6 must always be present.

 1. When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with other indicated methods.

 2. When there is a reason to believe that doses generally thought to be above the level otherwise attainable with other methods might improve control rates.

 3. In circumstances when the higher levels of precision associated with SBRT as compared to other radiation methods are necessary, i.e., clinically relevant.

 4. For the treatment of primary lesions, the intent of treatment must be curative with the exception of lesions within the pancreas or liver.

 5. For the treatment of metastatic lesions, there must be:

• the expectation of a long-term benefit (> 6 months) that could not have been attained with conventional therapy.

• The expectation of a complete eradication of the metastatic lesion that could not have been safely accomplished with conventional therapy, as evidenced by a dosimetric advantage for SBRT over other forms of radiation therapy.

 6. The patient’s record demonstrates why SBRT is considered the treatment of choice for the individual patient.

• Specifically, the record must address the lower risk to normal tissue, the lower risk of disease recurrence, and the advantages of the treatment over, conventional radiation therapy, IMRT or 3-dimensional conformal radiation.

• Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control must be maintained.

 

• SBRT will be considered medically reasonable and necessary only if the above criteria are met as specified for the following conditions:

 

• Spinal Lesions

o Previously untreated spinal metastases or spinal metastases that have recurred after conventional radiotherapy and clinical reasons preclude a surgical approach.

o Lung Cancer.

o Early stage Bronchogenic Carcinoma -treatment of early stage bronchogenic carcinomas in medically unresectable patients.

o Pulmonary Metastatic Disease -patient has limited pulmonary metastatic disease and no active disease elsewhere in the body.

o Patients that might otherwise be candidates for resection, but precluded by co-existing medical condition(s) or technically difficult lesion location.

o Recurrent Disease- Very selected cases for long-term palliative use.

 

• Liver Cancer

o Primary hepatocellular carcinoma- Patients who are not surgical candidates.

o Secondary metastases to the liver, not amenable to surgical resection. Generally limited to less than 4 simultaneous lesions.

 

• Pancreatic Cancer

o Palliative intent and selected cases for curative intent or unresectable.

 

• Kidney and Adrenal Gland

o Primary and metastatic tumors.

 

Limitations:

• Treatment for anything other than a severe symptom or serious threat to life or critical functions, not responsive or reasonably amenable to another therapy.

• Treatment unlikely to result in functional improvement or clinically meaningful disease stabilization, not otherwise achievable.

• In general, stereotactic radiosurgery is not indicated for cancers that are widespread with cerebral or extra-cranial metastases.

o The intent of treatment should be curative, except in cases where radiosurgery will provide the best palliation, resulting in significant quality of life.

• Patients with poor performance status (Karnofsky Performance Status < 40), - see Karnofsky Performance Status below* or Eastern Cooperative Oncology Group (ECOG) Performance Status > 3.

• A claim for stereotacticcingulotomy as a means of psychotherapy, considered investigational, per Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Part 2, Section 160.4.

• Lesions of bone, breast, uterus, ovary and other internal organs not listed above are not covered for primary definitive SBRT as literature does not support an outcome advantage over other conventional radiation modalities.

• Claims for primary prostate cancer will be developed (documentation requested) for medical review and payment considered on an individual case by case basis

o (Refer to the ‘Documentation Requirements’ section of this LCD).

 

• *Karnofsky Performance Scale (Perez and Brady, p 225)

o 100 Normal; no complaints, no evidence of disease.

o 90 Able to carry on normal activity; minor signs or symptoms of disease.

o 80 Normal activity with effort; some signs or symptoms of disease.

o 70 Cares for self; unable to carry on normal activity or to do active work.

o 60 Requires occasional assistance but is able to care for most needs.

o 50 Requires considerable assistance and frequent medical care.

o 40 Disabled; requires special care and assistance.

o 30 Severely disabled; hospitalization is indicated although death not imminent.

o 20 Very sick; hospitalization necessary; active supportive treatment is necessary.

o 10 Moribund, fatal processes progressing rapidly.

o 0 Dead.

 

• Eastern Cooperative Oncology Group: Performance Scale and corresponding Karnofsky Rating (Cancer Medicine 5th ed)

o 0 Fully active, able to carry on all pre disease activities without restriction Karnofsky 100).

o 1 Restricted in physically strenuous activity, but ambulatory and able to carry out work of a light or sedentary nature, for example, light housework/office work (Karnofsky 80-90).

o 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 (Karnofsky-70).

o 3 Capable of limited self-care, confined to bed or chair 50% or more of waking hours (Karnofsky 40-50).

o 4 Completely disabled; cannot carry on any self-care; totally confined to bed or chair (Karnofsky 30 or less).

o 5 Dead.

 

Coding Information

 

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

85x Critical Access Hospital

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0333 Radiology - Therapeutic and/or Chemotherapy Administration - Radiation Therapy

 

 

CPT/HCPCS Codes

 

 

77371 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; MULTI-SOURCE COBALT 60 BASED

77372 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; LINEAR ACCELERATOR BASED

77373 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS

G0339 IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED 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 SESSIONS PER COURSE OF TREATMENT

 

 

ICD-9 Codes that Support Medical Necessity

 

 

These are the only covered ICD-9-CM codes that support medical necessity under this LCD for procedure codes 77371, 77372, 77373, G0339 and G0340 for SRS:

 

147.0 MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX

147.1 MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX

147.2 MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX

147.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX

147.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX

147.9 MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE

160.1 MALIGNANT NEOPLASM OF AUDITORY TUBE MIDDLE EAR AND MASTOID AIR CELLS

160.2 MALIGNANT NEOPLASM OF MAXILLARY SINUS

160.3 MALIGNANT NEOPLASM OF ETHMOIDAL SINUS

160.4 MALIGNANT NEOPLASM OF FRONTAL SINUS

160.5 MALIGNANT NEOPLASM OF SPHENOIDAL SINUS

160.8 MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES

160.9 MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED

170.2 MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX

190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

190.1 MALIGNANT NEOPLASM OF ORBIT

190.2 MALIGNANT NEOPLASM OF LACRIMAL GLAND

190.3 MALIGNANT NEOPLASM OF CONJUNCTIVA

190.4 MALIGNANT NEOPLASM OF CORNEA

190.5 MALIGNANT NEOPLASM OF RETINA

190.6 MALIGNANT NEOPLASM OF CHOROID

190.7 MALIGNANT NEOPLASM OF LACRIMAL DUCT

190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE

190.9 MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED

191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES

191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE

191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE

191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE

191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE

191.5 MALIGNANT NEOPLASM OF VENTRICLES

191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS

191.7 MALIGNANT NEOPLASM OF BRAIN STEM

191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN

191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE

192.0 MALIGNANT NEOPLASM OF CRANIAL NERVES

192.1 MALIGNANT NEOPLASM OF CEREBRAL MENINGES

192.3 MALIGNANT NEOPLASM OF SPINAL MENINGES

194.3 MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

194.4 MALIGNANT NEOPLASM OF PINEAL GLAND

194.6 MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

198.4* SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM

198.89* SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

213.2 BENIGN NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX

225.0 BENIGN NEOPLASM OF BRAIN

225.1 BENIGN NEOPLASM OF CRANIAL NERVES

225.2 BENIGN NEOPLASM OF CEREBRAL MENINGES

225.3 BENIGN NEOPLASM OF SPINAL CORD

225.4 BENIGN NEOPLASM OF SPINAL MENINGES

227.3 BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

227.4 BENIGN NEOPLASM OF PINEAL GLAND

227.6 BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA

228.02 HEMANGIOMA OF INTRACRANIAL STRUCTURES

234.8* CARCINOMA IN SITU OF OTHER SPECIFIED SITES

237.0 NEOPLASM OF UNCERTAIN BEHAVIOR OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

237.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF PINEAL GLAND

237.3 NEOPLASM OF UNCERTAIN BEHAVIOR OF PARAGANGLIA

237.5* NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD

237.6* NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES

239.6* NEOPLASM OF UNSPECIFIED NATURE OF BRAIN

239.7* NEOPLASM OF UNSPECIFIED NATURE OF ENDOCRINE GLANDS AND OTHER PARTS OF NERVOUS SYSTEM

255.3 OTHER CORTICOADRENAL OVERACTIVITY

332.0 PARALYSIS AGITANS

333.1* ESSENTIAL AND OTHER SPECIFIED FORMS OF TREMOR

350.1 TRIGEMINAL NEURALGIA

350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS

351.1 GENICULATE GANGLIONITIS

351.8 OTHER FACIAL NERVE DISORDERS

351.9 FACIAL NERVE DISORDER UNSPECIFIED

352.0* DISORDERS OF OLFACTORY (1ST) NERVE

352.1* GLOSSOPHARYNGEAL NEURALGIA

352.2* OTHER DISORDERS OF GLOSSOPHARYNGEAL (9TH) NERVE

352.3* DISORDERS OF PNEUMOGASTRIC (10TH) NERVE

352.4* DISORDERS OF ACCESSORY (11TH) NERVE

352.5* DISORDERS OF HYPOGLOSSAL (12TH) NERVE

352.6* MULTIPLE CRANIAL NERVE PALSIES

352.9* UNSPECIFIED DISORDER OF CRANIAL NERVES

747.81* CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM

747.82 SPINAL VESSEL ANOLMALY

 

These are the only covered ICD-9-CM codes that support medical necessity under this LCD for procedure codes 77373, G0339 and G0340 for SBRT:

147.0 MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX

147.1 MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX

147.2 MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX

147.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX

147.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX

147.9 MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY

155.1 MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS

155.2 MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

157.0 MALIGNANT NEOPLASM OF HEAD OF PANCREAS

157.1 MALIGNANT NEOPLASM OF BODY OF PANCREAS

157.2 MALIGNANT NEOPLASM OF TAIL OF PANCREAS

157.3 MALIGNANT NEOPLASM OF PANCREATIC DUCT

157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

157.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS

157.9 MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

162.0 MALIGNANT NEOPLASM OF TRACHEA

162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS

162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG

162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG

162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG

162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS

189.1 MALIGNANT NEOPLASM OF RENAL PELVIS

194.0 MALIGNANT NEOPLASM OF ADRENAL GLAND

197.0 SECONDARY MALIGNANT NEOPLASM OF LUNG

197.7 MALIGNANT NEOPLASM OF LIVER SECONDARY

197.8* SECONDARY MALIGNANT NEOPLASM OF OTHER DIGESTIVE ORGANS AND SPLEEN

198.0 SECONDARY MALIGNANT NEOPLASM OF KIDNEY

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

198.4* SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

198.89* SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

227.6 BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA

234.8 CARCINOMA IN SITU OF OTHER SPECIFIED SITES

237.3 NEOPLASM OF UNCERTAIN BEHAVIOR OF PARAGANGLIA

239.7* NEOPLASM OF UNSPECIFIED NATURE OF ENDOCRINE GLANDS AND OTHER PARTS OF NERVOUS SYSTEM

* ICD-9-CM 197.8 is limited to secondary malignant neoplasms of pancreas and may not be used for other diagnoses.

* ICD-9-CM codes 198.4, 198.89, and 239.7 are all limited to use for lesions occurring either above the neck or in the spine.

 

 

Documentation Requirements

• The patient's record must support the necessity and frequency of treatment.

o Medical records should include not only the standard history and physical but also the patient's functional status and a description of current performance status (Karnofsky Performance Status or Eastern Cooperative Oncology Group Performance Scale).

o See Karnofsky Performance Scale and Eastern Cooperative Oncology Group Performance Scale listed under the Indications and Limitations of Coverage and/or Medical Necessity section of the LCD above.

• The patient’s record demonstrates why SBRT is considered the treatment of choice for the individual patient.

o Specifically, the record must address the lower risk to normal tissue, the lower risk of disease recurrence, and the advantages of the treatment over conventional radiation therapy, IMRT or 3-dimensional conformal radiation.

o Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control must be included.

• Documentation should include the date and the current treatment dose.

o A radiation oncologist and/or a neurosurgeon, as clinically indicated, must evaluate the clinical aspects of the treatment, and document and sign this evaluation as well as the resulting management decisions.

o A radiation oncologist and/or a neurosurgeon, and medical physicist must evaluate the technical aspects of the treatment and document and sign this evaluation as well as the resulting treatment management decisions.

• When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862 (a) of the Social Security Act.

• For prostate cancer, claims will be developed (documentation requested) for medical review and payment considered on an individual case by case basis.

• Documentation should include the information noted above, as well as the following information:

o Patient selection (stage and other favorable factors).

o Verification that the patient was informed of the range of therapy choices, including the risks and benefits of SBRT (especially the risk of long term toxicities).

o The rationale for SBRT as a treatment choice for the patient.

 

Treatment Logic

• Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) are noninvasive means of administering high-dose radiotherapy to discreet tumor foci in cranial or extracranial locations respectively.

• The two forms of treatment share certain overarching principles, namely, the use of image guidance and related treatment delivery technology for escalating the radiation dose to the tumor with as little radiation dose to the surrounding tissue as possible.

• Both methods are achieved with a “sterotactic” technique, implying that fiducial reference markers serve to align the treatment machine so that an internal lesion is targeted accurately; however, notable differences in clinical applications emerge given the vastly different anatomic and clinical consideration between cranial and extracranial target lesions.

 

Sources of Information and Basis for Decision

 

American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the American Society of Therapeutic Radiology and Oncology) (2007). AANS/CNS/ASTRO Definition of Stereotactic Radiosurgery. Retrieved on January 8, 2007 via Internet: http://www.aans.org/library/article. Definitions

 

American Cancer Society. Principles of Surgical Oncology Surgical Therapy Cancer Medicine 5th ed. Retrieved on September 9, 2008 via Internet at http://ww.ncbi.nlm.nih.gov/books.

 

American College of Radiology (ACR) and the American Society for Therapeutic Radiology and Oncology (ASTRO). (2006). Practice Guideline for the performance of stereotactic radiosurgery. Retrieved January 8, 2007 via Internet: http://www.acr.org.

 

American College of Radiology (ACR) and the American Society for Therapeutic Radiology and Oncology (ASTRO) (2006). Practice guideline for radiation oncology. Retrieved January 8, 2007 via Internet: http://www.acr.org.

 

American Society Therapeutic Radiation Oncology, Emerging technology Committee. (2008) Stereotactic Body Radiation Therapy for primary management of early stage, low intermediate risk for prostate cancer. Retrieved via Internet: http://www.astro.org. (Supports non-coverage of Prostate therapy)

 

American Society Therapeutic Radiation Oncology. The ASTRO/ACR Guide to Radiation Oncology Coding (2007).

 

Beitler, J., Makara, D., Silverman, P., et. al., Definitive, high-dose-per-fraction, conformal, stereotactic external radiation for renal cell carcinoma. Am J Clin Oncol 27 (6): 646-8. Kidney

 

Blue Cross and Blue Shield Association (2006). Stereotactic Radiosurgery and Stereotactic Radiotherapy Medical Policy.

 

Bucholz, R.D., Gagnon, G.J., Gerszten, P.C., Kresl, J.J., Levendag, P.C., Mould, R.F., & Schulz, R.A., (eds.) (2005). Robotic Radiosurery 1 (33) Cyberknife Society Press.

 

Crowley, R.W., Pouratian, N., Sheehan, J. (2006). Gamma knife surgery for glioblastoma multiforme. Neurosurgery Focus 20 (4): E17. Brain

 

FCSO LCD 30366, Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT), 11/29/2012

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Freeman, D., Friedland, J., Spellberg, D., Masterson, M.E., (2007). Cyberkinfe sterotactic radiosurgery in the treatment of low risk prostate carcinoma. 6th annual cyberknife users meeting presentation of Naples Community Hospital experiences. Prostate

 

Fuss, M., Thomas, C., Stereotactic Body Radiation Therapy: An ablative treatment option to primary and secondary liver tumors. Ann Surgl Onc 11 (2): 130-138. Liver

 

Gerszten, P. C., Orhasoglu, C., Burton, S.A., et. al., (yr). Cyberknife Frameless Stereotactic radiosurgery for spinal lesions. Clinical experience in 125 cases. J Neurosurg 55

(1): 89-98. Spine and sacrum

 

Gertzen, P.C., Burton, S.A., Ozhasoglu, C., Vogel, W.J., Welch, W.C., Barr, J., Friedland, D.M. (2005). Stereotactic radiosurgery for spinal metastases from renal cell carcinoma. J. Neurosurg: Spine 3: 288-295. Spine

 

Hof, H., Muenter, M., Oetzel, D., et al ,.(2007). Stereotactic single-dose radiotherapy (radiosurgery) of early stage non-small cell lung cancer (NSCLC) . Cancer lung

 

Kavanagh, B.D., Schefter, T.E., Cardenes, H., Stieber, V.W., Raben, D., Timmerman, R. D. , McCarter, M. D., Burri, S., Nedzi, L. A., Sawyer. T.E., Gaspar, L. E. (2006). Interim analysis of a prospective phase I/II trial of SBRT for liver metastases. Acta Oncologica 45: 848-855. Liver

 

Kavanagh, B.D., Timmerman, R.D. (2006). Stereotactic radiosurgery and sterotactic body radiation therapy: An overview of technical considerations and clinical applications. Hematology/Oncology Clinics of North America. 20 (1) introductory statement

 

IRSA Stereotactic Radiosurgery overview . Retrieved June 4, 2008 via Internet: http://www.irsa.org/radiosurgery.html

 

King, C., Lehmann, J. Adler, J., (2003). Cyberknife radiotherapy for localized prostate cancer: Rationale and technical feasibility. Technol Caner Res Treat 2 (1): 25-30.prostate

 

King,. C.R.. Brooks, J.D., Gill, H., Pawlicki, T., Cotrutz, C. Presti, J.C. (2008). (Article in press) Stereotactic body radiotherapy for localized prostate cancer: Interim results of a prospective phase II Clinical trial. Int. J. Radiation Oncology Biol. Phys. Prostate.

 

NCCN (2006). NCCN Clinical Practice Guidelines in Central Nervous System Cancers. Retrieved August 2008 via Internet: http://www.nccn.org

 

NCCN (2006). NCCN Clinical Practice Guidelines in Oncology (2007). Retrieved via Internet: http://www.nccn.org.

 

Other Medicare Contractor’s LCDs

 

Perez, C.A., et al 2003. (Eds.). Principles and Practice of Radiation Oncology, 4th Ed., Philadelphia, Lippincott-Raven.

 

San Diego Cyberknife Center (2006). Cyberknife clinical indications. Retrieved on January 6, 2007 via Internet: http://www.sdcyberknife.com/indications.htm.

 

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CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L30364 Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)