C9795, Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation of diagnosis (including relevant ICD-10 code) that matches a covered indication in the policy.
- Imaging reports (CT, MRI, angiography, PET-CT when applicable) demonstrating lesion location, size (e.g., tumor < 3 cm where required), and characteristics supporting the indication and unresectability or anatomical suitability for SRS/SBRT.
- Operative notes or neurosurgical evaluation documenting that lesion is unresectable or that the member is not a candidate for conventional surgery (when coverage is based on surgical ineligibility).
- Karnofsky Performance Scale (KPS) score documentation for brain metastases or other cranial malignancy indications (required KPS 80–100 for coverage of brain malignancies per policy).
Key Coverage Criteria
- 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)
- Histiocytosis of the intracranial region (localized disease treated with SRS)
3 Active Policies
AETNA-CPB-0083, Stereotactic Radiosurgery
REGENCE-SUR213, Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites
REGENCE-SUR214, Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites
Related Codes
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