Stereotactic Body Radiation Therapy

This policy covers stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) for precise, focal high‑dose treatment of extracranial and intracranial/spinal targets—examples include early‑stage NSCLC as an alternative to surgery, selected hepatocellular and pancreatic cases, low‑ to intermediate‑risk (and selected high‑risk with ADT) prostate cancer, spinal tumors, oligometastatic disease (1–3 lesions from specified primaries), benign cranial tumors, small AVMs, and recurrent or palliative malignant disease. Coverage is limited to highly selected patients (e.g., KPS ≥40/ECOG ≤3 with expected improvement and no disqualifying distant metastases for specific indications), is generally restricted to up to five fractions/sessions per course, must be delivered at experienced IGRT‑capable centers (or within trials), and is not supported for indications or fractionation beyond those explicitly listed.

"SBRT for extracranial sites requiring precise, focal radiation delivery; typically delivered in 1–5 fractions."