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Stereotactic Radiation Surgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

Coverage decision

Stereotactic Radiation Surgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) are covered benefits with conditions that are accepted on the claim.

  • Stereotactic Radiation Surgery (SRS) for Central Nervous System (CNS) primary and metastatic tumors is a covered benefit when the following criteria are met:
    • CNS primary or metastatic tumors
    • Patient functional status score, i.e., Karnofsky score, is greater than or equal to 50; and
    • Evaluation includes multidisciplinary team analysis (e.g., tumor board), including surgical input.
  • Stereotactic Body Radiation Therapy (SBRT) is covered when the following criteria are met:
    • For cancers of spine/paraspinal structures; or
    • For inoperable non‐small cell lung cancer, stage 1; and
    • Evaluation includes multidisciplinary team analysis (e.g., tumor board), including surgical input.
  • All other indications are Not Covered. 

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed SRS & SBRT on November 16, 2012. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that SRS & SBRT are covered benefits with conditions. Complete information on this HTCC determination is available here: http://www.hta.hca.wa.gov/stereotactic_radiation.html

Implementation of this Determination

Beginning July 15, 2013 all requests for SRS & SBRT require prior authorization.

For State Fund Claims

All requests for SRS & SBRT require prior authorization and will be reviewed by L&I’s occupational nurse consultant and claims manager.

  • By phone: To get the claims manager’s phone number, call the Claim Information line (1-800-831-5227)
  • By secure email: If you are the attending provider, IME, or concurrent care provider, log into to the Claims & Account Center (CAC)
For Crime Victims

Please contact the nurse consultant by one of the following modes of transmission: fax to (360) 902-5333 or call (360) 902-4896.

For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to: http://www.lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/FindEmps/Default.asp

Billing Codes
CPT ® Code
61796 - Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion
61797 - Each additional cranial lesions, simple
61798 - Complex cranial lesion
61799 - Each additional cranial lesion, complex
61800 - Application of stereotactic head frame for stereotactic radiosurgery
63620/1 - Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion (63621 for each additional spinal lesion)
77011 - Computed tomography guidance for stereotactic localization
77371 - Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesions(s) consisting of 1 session; multi-source Cobalt 60 based
77372 - As 77371, but linear accelerator based
77373 - Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
77432 - Stereotactic radiation treatment management of cranial lesions(s) (complete course of treatment consisting of 1 session)
77435 - Stereotactic body radiation therapy, tx management, per tx course, to 1 or more lesions, w/ image guidance, max 5 fractions
G0339 - Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment
G0340 - Image-guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions/ course of treatment
G0173 - Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session

 

Karnofsky performance status scale definitions.

Health Care Authority's Health Technology Assessment Program site.


For more information:
Contact information.

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