Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

SRS and SBRT are covered when used with stereotactic localization and image guidance for specified cranial, spinal, and extracranial tumors and select non-neoplastic cranial conditions, with SBRT limited to 1–5 fractions. Coverage requires documentation of diagnosis, prior treatments, performance status (KPS/ECOG), immobilization and image-guidance per fraction, and justification when treating previously irradiated regions; SRS/SBRT are not medically necessary for patients with poor performance status, widespread disease with limited life expectancy, or for primary sites expressly excluded (e.g., bone, breast, uterus, ovary for SBRT).

"Stereotactic Radiosurgery (SRS) is indicated for primary central nervous system malignancies as a boost or salvage therapy."

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