Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic radiosurgery (SRS) and stereotactic body radiotherapy 
(SBRT) (77373, G0339, G0340). 
 
You asked the Plan to pre-approve SRS and SBRT. You say that the enrollee still appears to be amazingly 
asymptomatic from a neurologic point of view. The enrollee on the latest MRI Is showing to have new areas of 
brain metastasis that you feel would best be treated by 3 to 5 fractions of SBRT Radiation Therapy as he has 
responded well in previous treatments. It is medically necessary for the enrollee. The Plan denied your request. 
The Plan says that the enrollee has a history of stage IV lung cancer x~4 years. There have been radiosurgeries 
of various doses to about ten intracranial targets in the past and various rounds of palliative extracranial 
radiotherapies. The request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SRS and SBRT. Our reviewer says that 
the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the ASTRO model policy for radiosurgery lists no restrictions on SRS based upon primary 
cancer type or number of lesions, or prior treatment (i.e., having undergone prior SRS) but rather emphasizes 
the need of SRS in enrollees with good performance status, and who are expected to have a reasonably long-
life expectancy warranting treatment. Generally, enrollees should have controlled extracranial disease or be 
candidates for systemic therapy that would be effective for the extracranial disease (as otherwise life 
expectancy would be poor). Perhaps more compelling (in that it is not from a Radiation Oncology society) are 
the NCCN guidelines, which state (and have stated since at least 2014) that radiosurgery can be considered for 
enrollees with multiple brain metastases with low-volume burden of disease. The guidelines recommend 
WBRT or SRS for these enrollees, and in a footnote state that SRS can be considered for enrollees with good 
performance status and low overall tumor volume. The guidelines explicitly state, The definition of limited 
brain metastases in terms of number of metastases or total intracranial disease volume is evolving and may 
depend on the specific clinical situation. In the absence of WBRT, it is expected that enrollees with brain 
metastases will need salvage therapy more frequently but treating with SRS for limited brain metastases vs. 
whole brain radiation has a major impact on preserving neurocognition and quality of life without detrimenting 
overall survival (Milano MT et al. Executive summary from American Radium Society's appropriate use 
criteria on neurocognition after stereotactic radiosurgery for multiple brain metastases. Neuro Oncol. 2020 Dec 
18;22(12):1728-1741.) This enrollee has 6 very small (low volume) brain metastases with no evidence of 
progression outside of the brain. I would think that SRS would be in accordance with accepted standards of 
care based on NCCN guidelines and ASTRO model policy which do not suggest limitations based on prior 
treatment. The LCD criteria appear to be met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SRS and SBRT have been met. Therefore, we decided that the Plan has to pre-
approve stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) (77373, G0339, G0340).  
 If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.