3.0 DESCRIPTION
3.1 Radiation
therapy is also known as radiotherapy, radiation treatment, x-ray
therapy, cobalt therapy, and proton beam therapy. The primary purpose
of radiation therapy is to eliminate or shrink localized cancers
(as opposed to cancers that have spread to distant parts of the
body).
3.2 Stereotactic radiosurgery/radiotherapy is a
method of delivering ionizing radiation to small intracranial targets.
Stereotactic radiosurgery entails delivering a high dose in a single
session. Stereotactic radiotherapy entails fractionating the dose
over a number of treatments.
3.2.1 There are three main variations
of stereotactic radiosurgery/radiotherapy: gamma beam or gamma knife,
linear accelerator (linac), and charged particle beam (proton or
helium ion). The three radiation delivery devices differ technically
in several ways: source of radiation, size and shape of the radiation
field, and range of radiation dosages.
3.2.2 The radiosurgical/radiotherapy
procedure is preceded by a process of localizing the target, which
can be performed with one or more of the following techniques: skull
x-ray, cerebral angiography, Computerized Tomography (CT), or Magnetic
Resonance Imaging (MRI).
4.0 POLICY
4.1 Radiation
therapy (fast neutron, hyperfractionated, and radioactive chromic
phosphate synoviorthesis) is covered for those indications documented
by reliable evidence as safe, effective and comparable or superior
to standard care (proven). For coverage on brachytherapy/radiation
therapy, see
Section 3.2.
4.2 Gamma knife radiosurgery/radiotherapy
is covered for the following indications. This list of indications
is not all inclusive. Other indications are covered when documented
by reliable evidence as safe, effective, and comparable or superior
to standard care (proven).
• Arteriovenous Malformations
(AVMs).
• Benign
brain tumors.
• Acoustic neuromas
(vestibular Schwannomas).
• Pituitary adenomas.
• Craniopharyngiomas.
• Other tumors of
the skull base.
• Pineal region tumors.
• Metastatic brain
tumors.
• High
grade gliomas (glioblastoma multiforme, anaplastic astrocytomas).
4.3 Linear
accelerator radiosurgery/radiotherapy is covered for the following
indications. This list of indications is not all inclusive. Other
indications are covered when documented by reliable evidence as safe,
effective, and comparable or superior to standard care (proven).
• AVMs.
• Acoustic neuromas
(vestibular Schwannomas).
• Metastatic brain
tumors.
4.4 Proton beam radiosurgery/radiotherapy
is covered for the following indications. This list of indications
is not all inclusive. Other indications are covered when documented
by reliable evidence as safe, effective, and comparable or superior
to standard care (proven).
• AVMs.
• Cushing’s disease
or acromegaly caused by pituitary microadenomas.
• As postoperative therapy
in patients who have undergone biopsy or partial resection of the chordoma
or low grade (I or II) chondrosarcoma of the basisphenoid region
(skull-base chordoma or chondrosarcoma) or cervical spine.
• As primary therapy
for patients with uveal melanoma, with no evidence of metastasis
or extrascleral extension, and with tumors up to 22 mm in largest
diameter and 14 mm in height.
• Prostate cancer.
• Meningioma.
• Low grade glioma (astrocytoma,
grade I-II).
• Glioblastoma
multiforme.
• Soft
tissue sarcoma (liposarcoma).
• Hodgkin’s disease
when conventional radiotherapy is contraindicated.
• Acoustic neuromas.
• As post-operative
therapy for sacral chordoma under the rare disease policy as described
in
Chapter 1, Section 3.1.
• Thymoma.
4.5 Helium
ion beam radiosurgery/radiotherapy is covered for the following
indications. This list of indications is not all inclusive. Other
indications are covered when documented by reliable evidence as safe,
effective, and comparable or superior to standard care (proven).
4.5.1 As primary
therapy for patients with melanoma of the uveal tract, with no evidence
of metastasis or extrascleral extension, and with tumors up to 24
mm in largest diameter and 14 mm in height.
4.5.2 As postoperative
therapy in patients who have undergone biopsy or partial resection
of the chordoma or low grade (I or II) chondrosarcoma of the basisphenoid
region (skull-base chordoma or chondrosarcoma) or cervical spine.
4.6 Extracranial
stereotactic radiosurgery/radiotherapy including image-guided robotic
linear accelerator-based stereotactic body radiotherapy (SBRT) (CPT
procedure codes 77435, 77373 and HCPCS codes G0339, G0340) and all
related medically necessary services and supplies (CPT procedure code
55876) are covered for the following indication.
• Primary and metastatic
lung carcinoma.
• Prostate
cancer.
4.7 Frameless stereotaxy (neuronavigation)
is covered for the following indications. This list of indications
is not all inclusive. Other indications are covered when documented
by reliable evidence as safe, effective, and comparable or superior
to standard care (proven).
• Localization, surgical
planning and guidance for intracranial tumors, skull base tumors, metastatic
brain tumors, AVMs, cavernomas, chordomas, and pituitary adenomas.
• Biopsy guidance.
• Cerebrospinal fluid
shunt placement.
• Surgery
for intractable epilepsy.
• Spinal surgery.
4.8 The frameless
stereotaxy device must be U.S. Food and Drug Administration (FDA)
approved. The following devices are FDA approved: StealthStation
System, The Operating Arm, ISG Viewing Wand, MKM System, and Philips
Easyguide. Other systems which are FDA approved are also covered.
4.9 High
energy neutron radiation treatment (Current Procedural Terminology
(CPT) procedure codes 77422 and 77423) is covered for adenoid cystic
carcinoma for the following indications:
• Unresectable, inoperable
or recurrent tumors.
• Locally advanced
disease.
• In
situations where surgical extirpation would cause considerable morbidity.
4.10 The off-label use of Selective Internal Radiation
Therapy (SIRT), also known as radioembolization, with yttrium-90
microspheres (resin or glass) for the treatment of unresectable
liver tumors from metastatic breast cancer is safe, effective, and
in accordance with nationally accepted standards of practice in
the medical community.
4.11 Intra-Operative Radiation
Therapy (IORT) is covered.
5.0 EXCLUSIONS
5.1 Helium ion
beam radiosurgery/radiotherapy for AVMs and ependymoma is unproven.
5.2 High energy neutron radiation treatment delivery,
single treatment area using a single port or parallel-opposed ports
with no blocks or simple blocking (CPT procedure code 77422) is
unproven (except for treatment of adenoid cystic carcinoma, see
paragraph 4.9).
5.3 High energy neutron radiation treatment delivery,
single treatment area using a single port or parallel-opposed ports
with no blocks or simple blocking one or more isocenter(s) with
coplanar or non-coplanar geometry with blocking and/or wedge, and/or
compensator(s) (CPT procedure code 77423) is unproven (except for
treatment of adenoid cystic carcinoma, see
paragraph 4.9).
5.4 Proton Beam Therapy (PBT) radiosurgery/radiotherapy
for the treatment of inoperable non-small cell lung cancer is unproven.
5.5 PBT for the treatment of recurrent
squamous cell carcinoma of the neck is unproven.
6.0 EFFECTIVE
DATES
6.1 February 26, 1986, for proton beam radiosurgery/radiotherapy
for AVMs.
6.2 March 1, 1988, for proton beam radiosurgery/radiotherapy
for patients with Cushing’s disease or acromegaly caused by pituitary
microadenoma.
6.3 October 6, 1988, for gamma beam (gamma knife)
radiosurgery/radiotherapy for treatment of AVM, benign brain tumors,
acoustic neuromas, pituitary adenomas, craniopharyngiomas, other
tumors of the posterior fossa and pineal region tumors.
6.4 January
1, 1990, for proton beam radiosurgery/radiotherapy for soft tissue
sarcoma (liposarcoma).
6.5 June 18, 1990, for proton
beam radiosurgery/radiotherapy for chordomas or chondrosarcomas.
6.6 January
1, 1994, for gamma beam (gamma knife) and linear accelerator radiosurgery/radiotherapy
for metastatic brain tumors.
6.7 January 1, 1996, for proton
beam radiosurgery/radiotherapy for uveal melanoma.
6.8 January
1, 1996, for helium ion beam radiosurgery/radiotherapy for uveal
melanoma and chordomas or chondrosarcomas.
6.9 April 1, 1996, for linear
accelerator radiosurgery/radiotherapy for AVMs and acoustic neuromas.
6.10 April 26,
1996, for proton beam radiosurgery/radiotherapy for prostate cancer.
6.11 October
1, 1997, for gamma knife radiosurgery/radiotherapy for high grade
gliomas (glioblastoma multiforme, anaplastic astrocytomas).
6.12 January
1, 1998, for extracranial stereotactic radiosurgery/radiotherapy
for lung carcinoma.
6.13 The date of FDA approval for
frameless stereotaxy.
6.14 October 24, 2014, for image-guided
robotic linear accelerator-based Stereotactic Body Radiation Therapy
(SBRT) and all related medically necessary services and supplies
for the treatment of prostate cancer.
6.15 July 4, 2014, for the off-label use of SIRT,
also known as radioembolization, with yttrium-90 microspheres (resin
or glass) for the treatment of unresectable liver tumors from metastatic
breast cancer.
6.16 February 16, 2016, for Proton
Beam Therapy (PBT) for the treatment of thymoma.
6.17 January 1, 2005, for IORT.