Stereotactic radiosurgery using a gamma-ray or linear accelerator unit may be considered medically necessary for the following indications:
trigeminal neuralgia refractory to medical management;
mesial temporal lobe epilepsy refractory to medical management when standard alternative surgery is not an option;
nonresectable, residual, or recurrent meningiomas;
glomus jugulare tumors;
malignant neoplastic intracranial lesion(s) (eg, gliomas, astrocytomas);
solitary or multiple brain metastases in patients having good performance status and no active systemic disease (defined as extracranial disease that is stable or in remission) (see Policy Guidelines section);
Stereotactic body radiotherapy may be considered medically necessary for the following indications:
primary or metastatic spinal or vertebral body tumors in patients who have received prior spinal radiotherapy;
spinal or vertebral metastases that are radioresistant (eg, renal cell carcinoma, melanoma, sarcoma);
patients with stage T1 or T2a non-small cell lung cancer (not >5 cm) showing no nodal or distant disease and who are not candidates for surgical resection;
primary or metastatic tumors of the liver as an alternative locoregional treatment for patients with inoperable primary or metastatic lesions;
primary renal cell carcinoma in patients who are not good surgical candidates or who have metastatic renal cell carcinoma;
oligometastases involving the lung, adrenal glands, and bone (other than spine or vertebral body).
When stereotactic radiosurgery or stereotactic body radiotherapy are performed using fractionation (defined in the Policy Guidelines section) for the medically necessary indications described above, it may be considered medically necessary.
Stereotactic radiosurgery is investigational for other applications including, but not limited to, the treatment of functional disorders (other than trigeminal neuralgia), including chronic pain and tremor.
Stereotactic body radiotherapy is investigational for prostate cancer, pancreatic adenocarcinoma, and other conditions except as outlined in the policy statements above.