Download Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS

Regence
Medicare Advantage Policy Manual
TOPIC: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic
Body Radiation Therapy (SBRT)
Section: Medicare Manual – Surgery
Approval Date: June 2016
Policy No: M-SUR16
Published Date: 07/01/2016
IMPORTANT REMINDER: The health plan’s Medicare Advantage Medical Policies are
developed to provide guidance for members and providers regarding coverage in accordance
with the member Evidence of Coverage (EOC) booklet. Benefit determinations are based in all
cases on any applicable EOC language and any applicable CMS policy. To the extent there
may be any conflict, applicable EOC language or applicable CMS policy take precedence over
the health plan’s Medicare Advantage Medical Policy.
MEDICARE MEDICAL POLICY CRITERIA
Note: See separate Medicare Advantage medical policy, Medicine, Policy No. 49 for nonstereotactic applications of particle beam radiation therapy (i.e., proton or helium ion). See
separate Medicare Advantage medical policy, Medicine, Policy No. 134 for intraocular
radiation therapy for age-related macular degeneration (choroidal neovascularization [CNV]).
CMS Coverage Manuals
None
National Coverage
Determination (NCD)
None
Noridian Healthcare Solutions
(Noridian) Local Coverage
Determinations (LCD) and
Articles (LCA)
Stereotactic Radiation Therapy: Stereotactic
Radiosurgery (SRS) and Stereotactic Body Radiation
Therapy (SBRT) (L34151)
**Scroll to the “Public Version(s)” section at the bottom of
the LCD for links to prior versions if necessary.
REFERENCES
1 - M-SUR16
None
CROSS REFERENCES
Charged Particle (Proton or Helium Ion) Radiation Therapy, Medicine, Policy No. M-49
Intraocular Radiation Therapy for Age-Related Macular Degeneration, Medicine, Policy No. M134
CODES NUMBER
DESCRIPTION
Coding for stereotactic radiosurgery typically consists of a series of CPT codes describing the
individual steps required; medical radiation physics, clinical treatment planning, attachment of
stereotactic head frame, treatment delivery and clinical treatment management.
Treatment Delivery
The codes used for treatment delivery will depend on the energy source used, typically either
photons or protons. For photons (i.e. with a Gamma knife or LINAC device [including
Cyberknife®]) nonspecific radiation therapy treatment delivery CPT codes may be used
based on the voltage of the energy source (i.e. codes 77402-77416).
CPT
32701
Thoracic target(s) delineation for stereotactic body radiation therapy
(SRS/SBRT), (photon or particle beam), entire course of treatment
77371
Radiation therapy delivery, stereotactic radiosurgery (SRS),
complete course of treatment of cranial lesion(s) consisting of 1
session; multi-source Cobalt 60 based
77372
Radiation therapy 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 fraction
77435
Stereotactic body radiation therapy, treatment management, per
treatment course, to 1 or more lesions, including image guidance,
entire course not to exceed 5 fractions
Note: Codes for treatment delivery primarily reflects the cost related to the energy source
used, and not physician work.
Clinical Treatment Management
77432
Stereotactic radiation treatment management of cerebral lesion(s)
(complete course of treatment consisting of one session.)
61796
Stereotactic radiosurgery (particle beam, gamma ray, or linear
2 - M-SUR16
CODES NUMBER
DESCRIPTION
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)
63620
Stereotactic radiosurgery (partical beam, gamma ray, or linear
accelerator); 1 spinal lesion
63621
Stereotactic radiosurgery (partical beam, gamma ray, or linear
accelerator); each additional spinal lesion (List separately in addition
to code for primary procedure)
HCPCS G0339
G0340
Image guided robotic linear accelerator-based stereotactic
radiosurgery, complete course of therapy in one session, or first
session of fractionated treatment.
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
3 - M-SUR16