BlueCross BlueShield of Tennessee Medical Policy Manual

Stereotactic Radiosurgery of Central Nervous System (CNS) Lesions

DESCRIPTION

Stereotactic radiosurgery (SRS) is a 3-dimensional conformal radiotherapy method that delivers highly focused, convergent radiotherapy beams on a target that is defined with 3-dimensional imaging techniques with the ability to spare adjacent radiosensitive structures. Stereotactic radiosurgery primarily refers to such radiotherapy applied to lesions within or immediately adjacent to the brain or spinal cord. 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. Stereotactic radiosurgery has been used for a range of malignant and nonmalignant conditions.

Several gamma ray emitting devices have received FDA clearance. The most commonly used is the Gamma Knife®, which is a fixed device used only for intracranial lesions. A number of LINAC movable platforms that generate high-energy photons have also received FDA clearance. Examples include the Novalis TX®, TrueBeam STx, CyberKnife®.  LINAC-based devices may be used for intracranial and extracranial lesions.

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. (2011). Evidence-based guideline update: treatment of essential tremor. Retrieved August 21, 2018 from www.aan.com.

BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2017). Stereotactic radiosurgery and stereotactic body radiotherapy (6.01.10). Retrieved August 20, 2018 from BlueWeb. (180 articles and/or guidelines reviewed)

Eekers, D.B.P., Pijnappel, E.N., Schijns, O.E.M.G., Colon, A., Hoeben, A., Zindler, J.D., et al (2018). Evidence on the efficacy of primary radiosurgery or stereotactic radiotherapy for drug-resistant non-neoplastic focal epilepsy in adults: a systematic review. Seizure, 55, 83-92. Abstract retrieved August 22, 2018 from PubMed database.

Feng, E.S., Sui, C.B., Want, T.X., & Sun, G.L. (2016). Stereotactic radiosurgery for the treatment of mesial temporal lobe epilepsy. Acta Neurologica Scandinavica, 134 (6), 442-451. Abstract retrieved August 22, 2018 from PubMed database.

McGonigal, A., Sahgal, A., DeSalles, A., Hayashi, M., Levivier, M., Ma, L., et al. (2017). Radiosurgery for epilepsy: systematic review and international stereotactic radiosurgery society (ISRS) practice guideline. Epilepsy Research, 137, 123-131. Abstract retrieved August 22, 2018 from PubMed database.

National Comprehensive Cancer Network. (2018). NCCN clinical practice guidelines in oncology (NCCN guidelines®). Central nervous system cancers (v.1.2018). Retrieved August 20, 2018 from the National Comprehensive Cancer Network.

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:  9/13/2018   

ID_BT

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