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.