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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Stereotactic radiation therapy (SRT) couples this anatomic accuracy and reproducibility with 
very high doses of highly precise, externally generated, ionizing radiation, thereby maximizing the ablative 
effect on the target(s) while minimizing collateral damage to adjacent tissues. SRT requires computer-assisted, 
three-dimensional planning and delivery with stereotactic and convergent-beam technologies, including, but 
not limited to, multiple convergent cobalt sources (e.g. Gamma Knife?), protons, multiple, coplanar or non-
coplanar photon arcs or angles (e.g. XKnife), fixed photon arcs or image-directed robotic devices (e.g. 
CyberKnife?) that meet the criteria. 
 
Stereotactic Radiosurgery (SRS) is a distinct discipline that utilizes externally generated ionizing radiation in 
certain cases to inactivate or eradicate a defined target(s) in the head or spine without the need to make an 
incision. The target is defined by high-resolution stereotactic imaging. To assure quality of patient care the 
procedure involves a multidisciplinary team consisting of a neurosurgeon, radiation oncologist, and medical 
physicist. 
 
SRS typically is performed in a single session, using a rigidly attached stereotactic guiding device, other 
immobilization technology and/or a stereotactic-guidance system, but can be performed in a limited number of 
sessions, up to a maximum of five. 
 
Technologies that are used to perform SRS include linear accelerators, particle beam accelerators, and 
multisource Cobalt 60 units. In order to enhance precision, various devices may incorporate robotics and real 
time imaging. 
 
Regardless of the number of sessions, both SRT and SRS procedures include the following components: 
 
    1. Position stabilization (attachment of a frame or frameless)  
    2. Imaging for localization (CT, MRI, angiography, PET, etc.)  
   3. Computer assisted tumor localization (i.e. Image Guidance)  
 4. Treatment planning - number of isocenters, number, placement and length of arcs or angles, beam size and 
weight, etc.  
    5. Isodose distributions, dosage prescription and calculation  
    6. Setup and accuracy verification testing  
   7. Simulation of prescribed arcs or fixed portals  
   8. Radiation treatment delivery 
 
Other radiation oncology professional and technical services required prior to the delivery of SRS are coded 
separately and may be appropriately billed by the radiation oncologist, when necessary, appropriate and 
consistent with Medicare policy. These codes are addressed in the separate LCDs: Radiation Oncology: 
External Beam/Teletherapy and Intensity Modulated Radiation Therapy. 
 
As the services are collegial in nature with different specialties providing individual components of the 
treatment, surgical assistants will not be reimbursed. 
 
 
Indications for SRS: 
 
    1. Primary central nervous system malignancies, generally under 5 cm.  
    2. Primary and secondary tumors involving the brain or spine parenchyma, meninges/dura, or immediately 
adjacent boney structures.  
    3. Benign brain tumors and spinal tumors such as meningiomas, acoustic neuromas, pituitary adenomas, and 
pineal cytomas.  
   4. Cranial arteriovenous malformations and hemangiomas.  
   5. Other cranial non-neoplastic conditions for which it has been proven effective, e.g., movement disorders 
such as Parkinson?s disease, essential tremor and other disabling tremor that are refractory to conventional 
therapy, such as severe, sustained trigeminal neuralgia not responsive to other modalities.  
    6. As a boost treatment for larger cranial or spinal lesions that have been treated initially with external beam 
radiation therapy or surgery (i.e., grade III and IV gliomas, oligodendrogliomas, sarcomas, chondrosarcomas, 
chordomas, and nasopharyngeal or paranasal sinus malignancies).  
    7. Metastatic brain or spine lesions, generally limited in number, with stable systemic disease, Karnofsky 
Performance Status 70 or greater (or expected to return to 70 or greater with treatment), and otherwise 
reasonable survival expectations.  
   8. Relapse in a previously irradiated cranial or spinal field where the additional stereotactic precision is 
required to avoid unacceptable vital tissue radiation. 
 
Limitations: 
Coverage will be denied for each of the following:   
 
    1. Treatment for anything other than a severe symptom or serious threat to life or critical functions, not 
responsive or reasonably amenable to another therapy.   
   2. Treatment unlikely to result in functional improvement or clinically meaningful disease stabilization, not 
otherwise achievable.  
   3. Patients with wide-spread cerebral or extra-cranial metastases   
   4. Patients with poor performance status (Karnofsky Performance Status less than 40), - see Karnofsky 
Performance Status below.   
   5. A claim for stereotactic cingulotomy as a means of psychotherapy, is considered to be investigational.   
  6. For ICD-10-CM code G25.0, essential tremor, coverage is limited to the patient who cannot be controlled 
with medication, has major systemic disease or coagulopathy, and who is unwilling or unsuited for open 
surgery. Coverage is further limited to unilateral thalamotomy. Gamma Knife pallidotomy remains non-
covered and will be denied. 
 
Karnofsky Performance Scale (Perez and Brady, p 225) 
100 Normal; no complaints, no evidence of disease 
90 Able to carry on normal activity; minor signs or symptoms of disease 
80 Normal activity with effort; some signs or symptoms of disease 
70 Cares for self; unable to carry on normal activity or to do active work 
60 Requires occasional assistance but is able to care for most needs 
50 Requires considerable assistance and frequent medical care 
40 Disabled; requires special care and assistance 
30 Severely disabled; hospitalization is indicated although death not imminent 
20 Very sick; hospitalization necessary; active supportive treatment is necessary 
10 Moribund, fatal processes progressing rapidly 
0 Dead  
 
 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Stereotactic Radiosurgery 
(L34223). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.