BlueCross BlueShield of Tennessee Medical Policy Manual

Stereotactic Radiosurgery of Central Nervous System (CNS) Lesions

DESCRIPTION

Stereotactic radiosurgery (SRS) is a method of focused, external irradiation that uses multiple convergent beams to deliver high doses of radiation to precisely targeted intracranial lesions. SRS may be delivered as a single fraction treatment or as multiple treatments based on proximity to critical structures. SRS differs from conventional external beam radiotherapy (EBRT), which involves exposing large areas of tissue to relatively broad fields of radiation over multiple sessions. The goal is to optimize the therapeutic effect on the tumor and control side effects of radiation on the surrounding healthy tissue.  This complex, precise procedure requires the use of a stereotactic head frame for careful positioning of the individual for radiation delivery within millimeters of the target lesion, sparing normal brain tissue the consequences of high-dose radiation.

Intracranial lesions include: arteriovenous malformations; acoustic neuromas; pituitary adenomas; nonresectable, residual, or recurrent meningiomas; craniopharyngiomas; glomus jugulare tumors; solitary or multiple brain metastases in individuals with good performance status and no active systemic disease; primary malignancies of the central nervous system including, but not limited to, high-grade gliomas; trigeminal neuralgia refractory to medical management; epilepsy; functional disorders other than trigeminal neuralgia; tremors; chronic pain.

Different instruments are used for stereotactic radiosurgery according to their energy source: gamma-rays (e.g. Gamma Knife®), or linear-accelerator (LINAC) units using high energy photons (e.g., Novalis TX®, TrueBeam STx, CyberKnife®).

POLICY

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

There is an absence of adequate peer-reviewed literature demonstrating the effectiveness of stereotactic radiosurgery for those conditions listed as investigational.

SOURCES

American Academy of Neurology. (2005). Practice parameter: therapies for essential tremor. Retrieved September 11, 2017 from www.neurology.org.

American Academy of Neurosurgery. (2012). Stereotactic radiosurgery. Retrieved August 17, 2012 from http://www.aans.org.

American College of Radiology / American Society of Radiation Oncology. (2011). Practice guideline for the performance of stereotactic radiosurgery. Retrieved August 21, 2012 from: http://www.acr.org.

American College of Radiology. (1999, Revised 2012). ACR appropriateness criteria® for single brain metastasis. Retrieved September 21, 2016 from http://www.guideline.gov.  (NGC#009678).

American College of Radiology. (1999, Revised 2014). ACR appropriateness criteria® for multiple brain metastases. Retrieved September 21, 2016 from http://www.guideline.gov.  (NGC#010461).

BlueCross BlueShield Association. Medical Policy Reference Manual. (8:2015). Stereotactic radiosurgery and stereotactic body radiotherapy (6.01.10). Retrieved September 11, 2017 from BlueWeb. (125 articles and/or guidelines reviewed)

Cahaba Government Benefits Administrators, LLC. (2015, October) LCD: Radiology: stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) (L34283). Retrieved September 11, 2017 from https://www.cms.gov.

Narayanasamy, G., and Smith, A. (2013, August) Brain dose from gamma knife. American Association of Physicists in Medicine 40 (9). (Level 3 evidence)

National Comprehensive Cancer Network. (2017, January). NCCN clinical practice guidelines in oncology (NCCN guidelines®). Central nervous system cancers (V.1.2017). Retrieved September 11, 2017 from http://www.nccn.org. 

Thenier-Villa, J., Galárraga-Campoverde, R., Martínez, R., De La Lama, Z., Martínez C., Muñoz, G. et al. (2017, July).  Linear accelerator stereotactic radiosurgery of central nervous system arteriovenous malformations: A 15-year analysis of outcome-related factors in a single tertiary center. World Neurosurgery, 7 (103), 291-302. Abstract retrieved September 11, 2017 from PubMed database.

U. S. Food and Drug Administration. (2005, September). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K052325 (Cyberknife®). Retrieved August 21, 2012 from http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2009, February). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K082775 (PreScision™). Retrieved August 21, 2012 from http://www.accessdata.fda.gov. 

Winifred S. Hayes. Medical Technology Directory. (2015, February; Last update search February 2017). Stereotactic radiosurgery for trigeminal neuralgia and movement disorders. Retrieved September 11, 2017 from www.Hayesinc.com/subscribers. (80 articles and/or guidelines reviewed)

ORIGINAL EFFECTIVE DATE:  3/1988

MOST RECENT REVIEW DATE:  10/26/2017

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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