BlueCross BlueShield of Tennessee Medical Policy Manual

Stereotactic Radiosurgery of Central Nervous System (CNS) Lesions


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®).




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


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

American Academy of Neurosurgery. (2012). Stereotactic radiosurgery. Retrieved August 17, 2012 from

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

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

American College of Radiology. (1999, Revised 2014). ACR appropriateness criteria® for multiple brain metastases. Retrieved September 21, 2016 from  (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

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 

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

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 

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 (80 articles and/or guidelines reviewed)




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