BlueCross BlueShield of Tennessee Medical Policy Manual

Stereotactic Radiosurgery of Central Nervous System (CNS) Lesions

DESCRIPTION

Stereotactic radiosurgery (SRS) is a method of external irradiation that uses multiple convergent beams to deliver a high single dose of radiation to a radiographically well-circumscribed treatment volume. This complex, precise procedure requires the use of a stereotactic head frame with the radiation delivery system resulting in a rapid dropoff in radiation dose within millimeters of the target lesion, sparing normal brain the consequences of high-dose radiation. The technique differs from conventional radiotherapy, which involves exposing large areas of intracranial tissue to relatively broad fields of radiation over a number of sessions.

Three different technological instruments represent the basic forms of stereotactic radiosurgery: gamma-ray (gamma knife), linear-accelerator (LINAC), and proton-beam. The differences in the various systems are summarized in the following table:

Charged particle radiation can also be used without stereotactic guidance. In this setting, the use of charged particles is referred to as proton, helium, or neutron radiation therapy and is not addressed by this policy.

POLICY

• Stereotactic radiosurgery (e.g., gamma, linac, proton beam) for the treatment of arteriovenous malformations, acoustic neuromas, pituitary adenomas, meningiomas (non-resectable, residual or recurrent), solitary or multiple brain metastases, primary malignancies of the CNS, and trigeminal neuralgia refractory to medical management is considered medically necessary.

• Stereotactic radiosurgery (e.g., gamma, linac, proton beam) for the treatment of other central nervous system lesions and disorders, including but not limited to, the following: epilepsy, headaches, essential tremors, Parkinson's (e.g., tremor, rigidity), and neuro-psychological conditions is considered investigational.

See also:  Proton or Helium Ion Beam (Charged Particle) Radiation Therapy

IMPORTANT REMINDER

We develop Medical Policies to provide guidance to Members and Providers.  This Medical Policy relates only to the services or supplies described in it.  The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy.  For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed.  If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.

ADDITIONAL INFORMATION

There is an absence of adequate peer-reviewed literature demonstrating the effectiveness of stereotactic radiosurgery for those conditions listed as investigational and an absence of comparison to currently accepted treatment modalities with well-defined, clinically relevant health outcomes.

SOURCES

American College of Radiology. (2006). Practice guideline for the performance of stereotactic radiosurgery. Retrieved February 22, 2011 from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/ro/stereotactic_radiosurgery.aspx.

Aoyama, H., Shirato, H., Tago, M., Nakagawa, K., Toyoda, T., Hatano, K., et al. (2006). Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: A randomized controlled trial. JAMA, 295 (21), 2483-2491. (Level 1 Evidence - Independent study)

Banghoo, S., Linskey, M., Kalkanis, S. (2011) Evidence-based guidelines for the management of brain metastases. Neurosurgery Clinics of North America, 22 (1), 97-104.

BlueCross BlueShield Association. Medical Policy Reference Manual. (9:2010). Stereotactic radiosurgery and stereotactic body radiotherapy (6.01.10). Retrieved February 8, 2011 from BlueWeb. (35 articles and/or guidelines reviewed)

ECRI Institute. Health Technology Information Service. Emerging Technology (TARGET) Evidence Report. (2006, March). Frameless stereotactic radiosurgery (overview). Retrieved February 22, 2011 from ECRI Institute. (26 articles and/or guidelines reviewed)

International Radiosurgery Association. Radiosurgery Practice Guideline Initiative. (2009, March). Stereotactic radiosurgery for patients with intracranial arteriovenous malformations (AVM). Retrieved February 22, 2011 from http://www.irsa.org/AVM%20Guideline.pdf.

International Radiosurgery Association. Radiosurgery Practice Guideline Initiative. (2003, September). Stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management. Retrieved February 22, 2011 from http://www.irsa.org/TN%20Guideline.pdf.

International Radiosurgery Association. Radiosurgery Practice Guideline Initiative. (2008, May). Stereotactic radiosurgery for patients with metastatic brain tumors. Retrieved February 22, 2011 from http://www.guidelines.gov/content.aspx?id=12826.

International Radiosurgery Association. Radiosurgery Practice Guideline Initiative. (2004, April). Stereotactic radiosurgery for patients with pituitary adenomas. Retrieved February 22, 2011from http://www.irsa.org/Pituitary%20Guideline.pdf.

International Radiosurgery Association. Radiosurgery Practice Guideline Initiative. (2004, April). Stereotactic radiosurgery for patients with vestibular schwannomas. Retrieved February 22, 2011from http://guideline.gov/content.aspx?id=9312&search=Stereotactic+radiosurgery%2C+not+otherwise+specified.

Likhterov, I., Allbright, R. M., & Selesnick, S. H. (2007). LINAC radiosurgery and radiotherapy treatment of acoustic neuromas. Otolaryngologic Clinics of North America, 40 (3), 541–570.

National Comprehensive Cancer Network. (2011, February). NCCN clinical practice guidelines in oncology. Central nervous system cancers (V.2.2011). Retrieved February 22, 2011 from http://www.nccn.org/professionals/physician_gls/pdf/cns.pdf.

National Institute for Health and Clinical Excellence (NICE). (2004, August). Stereotactic radiosurgery for trigeminal neuralgia using the gamma knife. Retrieved February 22, 2011 from http://www.nice.org.uk/nicemedia/pdf/ip/IPG085guidance.pdf.

U. S. Food and Drug Administration. (2005, September). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K052325. Retrieved February 22, 2011 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=19284.

U. S. Food and Drug Administration. (2009, February). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K082775. Retrieved February 22, 2011 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=29036.

Winifred S. Hayes. Medical Technology Directory. (2009, January; last update search January 21, 2011). Stereotactic radiosurgery for arteriovenous malformations and intracranial tumors. Retrieved January 22, 2009 from www.Hayesinc.com/subscribers. (107 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  3/1988

MOST RECENT REVIEW DATE:  4/14/2011  

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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