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.