32701
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.08
Facility
$188.05
Non-Facility
$188.05
Documentation Required
- "Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews." Documentation of performance status: KPS score and/or ECOG performance status (policy uses KPS ≥ 70% or ECOG 0-2 as threshold in multiple indications). Imaging documentation to establish number of lesions and cumulative tumor volume (e.g., for brain metastases: up to 10 lesions or cumulative tumor volume < 15 cc). Imaging or clinical documentation demonstrating absence of leptomeningeal metastases when required. Pathology or diagnostic documentation to exclude lymphoma, germ cell tumor, or small cell carcinoma when indicated for brain metastasis eligibility. For repeat stereotactic radiation therapy: restaging studies documenting stable extracranial disease dated within the past two months. Documentation of life expectancy (e.g., clinical notes) when required (policy specifies life expectancy > 6 months for repeat brain stereotactic therapy and at least 6 months for oligometastatic disease). For NSCLC definitive treatment: thoracic surgery evaluation documentation if patient is refusing surgery or is deemed medically inoperable. For extracranial oligometastatic disease: documentation that primary tumor was treated definitively at least 3 months prior with no progression at primary site and count of metastatic lesions since diagnosis including previously treated lesions. For SBRT palliative spine treatment: documentation that treatment plan uses ≤ 2 fractions and that there is no spinal cord compression or cauda equina compression. For prior treatments: documentation of prior whole brain radiation therapy, prior local therapies (e.g., prior SBRT, surgery, RFA) when relevant to counting lesions or retreatment eligibility. Tumor stage and nodal status documentation where required (e.g., NSCLC Stage I or IIA with negative mediastinal lymph nodes; renal cancer Stage I; HCC/pancreatic/prostate without evidence of distant metastasis). Documentation of number and location of metastases with appropriate staging imaging (explicit in ASTRO/ESTRO and ISRS statements: e.g., 'up to five distant metastases, diagnosed with appropriate imaging'). Multidisciplinary tumor board documentation when selecting SBRT/SRS versus surgery or other local therapies ('after discussion in a multidisciplinary tumor board'). Histologic confirmation when indicated (e.g., 'Its specific role is highly dependent on tumor histology and as such, all efforts should be made to obtain a reliable histologic diagnosis' for pineal region tumors). Performance status and functional scores as appropriate (e.g., KPS ≥70 used in Iyengar trial; ECOG 0–2 required in Sahgal spinal metastasis trial). Pain assessment documentation (e.g., MRI-confirmed painful spinal metastasis with Brief Pain Inventory pain score ≥2 in the Sahgal trial). Spinal-specific assessments where applicable: MRI confirmation of spinal metastasis, documentation of Spinal Instability Neoplastic Score (SINS) and involvement of vertebral segments (Sahgal trial required ≤3 consecutive vertebral segments and SINS <12). Prior treatment history: documentation of prior systemic therapies, prior radiation (including doses and fields), prior surgeries, and prior embolizations (important for AVM, recurrent glioma, and re-irradiation decisions). Tumor size/volume and relationship to organs at risk (OARs) and justification that OAR constraints can be met (e.g., peripheral vs central lung location, distance to critical serial organs for single-fraction SBRT). Plans and dosimetry demonstrating BED and fractionation consistent with guideline recommendations (e.g., higher BED10 typically >75 Gy associated with optimal local control for SBRT alone; ASTRO SBRT dose recommendations for bone metastases). Documentation of patient counseling and informed consent including discussion of risks (e.g., increased risk of severe toxicity for ultracentral lung lesions, risks of hemorrhage during latency for AVMs, potential hypopituitarism for pituitary adenomas). For trials or indications supported by specific inclusion criteria, documentation that the patient meets those criteria (examples from trials: biopsy-proven disease, absence of EGFR/ALK mutations where specified, number of metastases limits, interval since frontline therapy/induction chemotherapy response). When re-irradiation is considered, documentation of cumulative normalized total dose and rationale to avoid excessive brain toxicity (examples: cumulative doses >100 Gy discussed in recurrent glioma series).
Key Coverage Criteria
- Acoustic neuroma (vestibular schwannoma) Brain metastasis when one of the following criteria is met: Newly diagnosed brain metastasis and all the following criteria are met: Individual has a good performance status [Karnofsky Performance Status (KPS) score ≥ 70% or Eastern Cooperative Oncology Group (ECOG) performance status of 0-2] Absence of leptomeningeal metastases Individual does not have a diagnosis of lymphoma, germ cell tumor, or small cell carcinoma Has up to 10 lesions or cumulative tu [...]
- Pituitary adenomas (secretory pituitary adenomas; SRS)
- Trigeminal neuralgia (Gamma Knife SRS)
- Medial thalamotomy/medial temporal procedures for intractable pain or epilepsy (SRS/Gamma Knife)
- Spinal lesions including chordomas of spine and sacrum (high-dose single-fraction radiotherapy/SRS) and spinal arteriovenous malformations (stereotactic radiosurgery / fractionated approaches)
- Intramedullary spinal cord neoplasms (role of SRS reviewed)
7 Active Policies
UHC-POL-stereotactic-body-radiation-therapy-radiosurgery — Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery
UMR-POL-UMR-stereotactic-body-radiation-therapy-radiosurgery — Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery
SUREST-POL-SUREST-stereotactic-body-radiation-therapy-radiosurgery — Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery
HUMANA-STEREOTACTIC-RADIOSURGERY-AND-STEREOTACTIC-BODY-RADIATION-THERAPY-MA — Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy - Medicare Advantage
Related Codes
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