61800
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.19
Facility
$145.63
Non-Facility
$145.63
Documentation Required
- All documentation must be available upon request and the medical record must support the medical necessity and frequency of treatment.
- The medical record must document the critical nature of the anatomy or other circumstances necessitating stereotactic treatment, the patient's functional status including Karnofsky Performance Status, the treatment date(s), and the current treatment dose.
- When requesting individual consideration at redetermination, providers must submit all relevant medical records and supporting literature, including at minimum two Phase II studies or one Phase III study for Contractor Medical Director review.
- If billing more than allowed units of CPT 77334 (total units >6 or units > isocenters+3), document factors such as multiple isocenters, target volume irregularity, proximity to critical structures, or other reasons justifying additional dosimetry/treatment device units.
Key Coverage Criteria
- Stereotactic radiosurgery (SRS) is typically furnished as a single session; when more than one session is required, bill using stereotactic body radiation therapy (SBRT) codes instead of SRS codes.
- Coverage on an individual (redetermination/appeal) basis may be considered for lesions that require a high radiation dose per fraction to avoid exposure of surrounding tissues when documentation and supporting literature are provided.
- Radiation therapy is covered when the patient's medical record documents medical necessity consistent with LCD L39553.
- Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiation Therapy (SBRT) is covered for oligometastatic disease when documentation justifies aggressive local therapy to one or more metastatic deposits for total disease clearance or to reduce systemic disease burden with a specifically defined clinical benefit.
- SRS or SBRT is covered for palliation or recurrent disease when tumor cannot be treated as effectively or safely by other radiotherapy methods due to proximity to previously irradiated volumes and beneficiary-unique facts are documented.
- Radiation therapy for non-cancer diagnoses (e.g., epilepsy, trigeminal/facial nerve conditions, movement disorders, Parkinson's disease, tremor) may be covered only when prior therapies tried and failed are clearly documented with names, durations, and response.
15 Active Policies
L35076 — Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
J06
A56874 — Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
J06
L39553 — Radiation Therapies
CARELON-proton-beam-therapy-2022-03-13 — Proton Beam Therapy
Related Codes
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