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Horizon BCBSNJ
Uniform Medical Policy ManualSection:Radiology
Policy Number:100
Effective Date: 07/01/2019
Original Policy Date:09/25/2012
Last Review Date:04/14/2020
Date Published to Web: 04/26/2013
Subject:
Radiation Therapy for Primary Craniospinal Tumors and Neurologic Conditions

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Over the past several decades, methods to plan and deliver radiation therapy have evolved in ways that permit more precise targeting of tumors with complex geometries. Earlier methods involved two-dimensional treatment planning based on flat images, and radiation beams with cross-sections of uniform intensity that were sequentially aimed at the tumor along 2 or 3 intersecting axes. These methods were collectively termed conventional external beam radiation therapy (EBRT).

Subsequent enhancement evolved using 3-dimensional images, usually from computed tomography (CT) scans, to delineate the tumor, its boundaries with adjacent normal tissue, and organs at risk for radiation damage. Radiation oncologists used these images, displayed from a "beam's-eye-view", to shape each of several beams (e.g., with compensators, blocks, or wedges) to conform to the patient's tumor geometry perpendicular to the beam's axis. Computer algorithms were developed to estimate cumulative radiation dose delivered to each volume of interest by summing the contribution from each shaped beam. Methods also were developed to position the patient and the radiation portal reproducibly for each fraction, and immobilize the patient, thus maintaining consistent beam axes across treatment sessions. However, "forward" planning used a trial and error process to select treatment parameters (the number of beams and the intensity, shape, and incident axis of each beam). The planner/radiotherapist modified one or more parameters and recalculated dose distributions, if analysis predicted underdosing for part of the tumor or overdosing of nearby normal tissue. Furthermore, since beams had uniform cross-sectional intensity wherever they bypassed shaping devices, it was difficult to match certain geometries (e.g., concave surfaces). Collectively, these methods are termed 3-dimensional conformal radiation therapy (3D-CRT).

Other methods were subsequently developed to permit beam delivery with non-uniform cross-sectional intensity. This often relies on a device (multi-leaf collimator, MLC) situated between the beam source and patient that moves along an arc around the patient. As it moves, a computer varies aperture size independently and continuously for each leaf. Thus, MLCs divide beams into narrow "beamlets", with intensities that range from zero to 100% of the incident beam. Beams may remain on as MLCs move around the patient (dynamic MLC), or they may be off during movement and turned on once the MLC reaches prespecified positions ("step and shoot" technique). Another method of delivering radiation beam uses a small radiation portal emitting a single narrow beam that moves spirally around the patient, with intensity varying as it moved. This method, also known as tomotherapy or helical tomotherapy, is described as the use of a linear accelerator inside a large "donut" that spirals around the body while the patient laid on the table during treatment. Each method (MLC-based or tomotherapy) is coupled to a computer algorithm for "inverse" treatment planning. The planner/radiotherapist delineates the target on each slice of a CT scan, and specifies that target's prescribed radiation dose, acceptable limits of dose heterogeneity within the target volume, adjacent normal tissue volumes to avoid, and acceptable dose limits within the normal tissues. Based on these parameters and a digitally-reconstructed radiographic image of the tumor and surrounding tissues and organs at risk, computer software optimizes the location and shape of beam ports, and beam and beamlet intensities, to achieve the treatment plan's goals. Collectively, these methods are termed intensity-modulated radiation therapy (IMRT).

According to ECRI Institute, there are two different approaches to image-guided radiation therapy that are in current use: pre-treatment imaging and real-time guidance. IMRT is an example of a method that uses pre-treatment imaging to prepare a treatment plan. In contrast, real-time guidance utilizes real-time imaging (at the time of treatment) to guide treatment. It provides real-time, online images of the radiation target area from a computed tomography (CT) scanner before, during, and after therapy. Patient positioning, radiation field alignment, and collimator positioning can be verified and adjusted before and during irradiation. This approach should, in theory, provide more accurate radiation delivery than conventional IMRT. Organ motion, day-to-day variations in tumor position, and differences in patient positioning in each treatment session could be taken into account with real-time imaging.

Policy:

(NOTE: This policy only applies to adult members. It does not apply to pediatric members.

For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)

  1. Complex, three-dimensional conformal radiation therapy (3DCRT), or Intensity-Modulated Radiation Therapy (IMRT) techniques are considered medically necessary for:
    1. The treatment of primary malignant gliomas of the brain in any of the following cases:
      1. Diagnosed by biopsy or resection
        1. Low grade tumors (WHO grade I-II)
          1. Up to 30 fractions
          2. 3DCRT/IMRT
          3. Procarbazine, lomustine (CCNU) and vincristine (PVC) should be considered upon the completion of radiation therapy.
        2. High grade tumors (WHO grade III-IV)
          1. Up to 33 fractions
          2. 3DCRT/IMRT
          3. Radiation therapy combined with temozolomide is the current standard of care.
        3. In a poorly performing or elderly individual, a hypofractionated-accelerated course may be effective. Typical fraction schedules are 34 Gy/10 fractions, 40.05 Gy/15 fractions, or 50 Gy/20 fractions.
    2. Recurrent disease with good prognostic factors including an Eastern Cooperative Oncology Group (ECOG) status of 0, 1, or 2.
    3. Proton beam therapy
      (NOTE: Please refer to a separate policy on 'Proton Beam Therapy' - Policy #011 in the Radiology section.)
    4. Craniospinal irradiation (CSI) in ependymoma, adult medulloblastoma and primitive neuroectodermal tumors (PNET).
      1. Up to 20 fractions depending on risk of recurrence and use of concurrent chemotherapy and a boost for up to a combined total of 33 fractions including CSI.
  2. Stereotactic Radiosurgery (SRS) or Fractionated Stereotactic Radiotherapy (FSRT) is considered medically necessary for reirradiation of recurrent inoperable malignant gliomas in individuals who maintain a good performance status.
  3. Brachytherapy is considered investigational for the treatment of a malignant glioma brain tumor.
  4. Complex, 3DCRT, or IMRT techniques are medically necessary for the treatment of a primary central nervous system (PCNS) lymphoma for any of the following:
    1. A young adult with good performance status and good response to chemotherapy
    2. Poor response to chemotherapy
    3. Without chemotherapy in an individual with a poor performance status, or who is severely immunocompromised
    4. Presence of ocular disease
    5. Recurrent disease
  5. 3DCRT, IMRT, or SRS is considered medically necessary for the treatment of the following benign conditions:
    1. Arteriovenous (AV) malformations (only SRS)
    2. Benign brain tumors including any of the following:
      1. Acoustic neuroma
      2. Craniopharyngioma
      3. Glomus tumor
      4. Hemangioblastoma
      5. Meningioma
      6. Pineocytoma
      7. Pituitary adenoma
      8. Schwannoma
    3. Cavernous malformations

      Please note that a maximum of 5 fractions is authorized for SRS. For an individual being treated with more than 5 fractions, 3DCRT or IMRT technique should be requested.
  6. SRS is medically necessary for any of the following diseases that are refractory to medical treatment and/or invasive neurosurgical treatment:
    1. Epilepsy
    2. Parkinson's disease
    3. Essential tremor
    4. Familial tremor classifications with major systemic disease
    5. Trigeminal neuralgia

      Authorization for this group of diseases will only be granted once all standard treatments have proven to be ineffective.
  7. 3DCRT, IMRT, or SRS is medically necessary for the treatment of an inoperable primary spinal tumor with compression or intractable pain.
  8. Proton Beam Therapy - (Please refer to a separate policy on 'Proton Beam Therapy' - Policy #011 in the Radiology Section.)



Medicare Coverage:
There is no National Coverage Determination (NCD) for Radiation Therapy for Primary Cranial and Spinal Tumors and Neurologic Conditions. In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for Complex, three-dimensional conformal radiation therapy (3DCRT), stereotactic radiosurgery (SRS), and Brachytherapy. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy for Complex, three-dimensional conformal radiation therapy (3DCRT), stereotactic radiosurgery (SRS), and Brachytherapy.

Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued a determination for Intensity-Modulated Radiation Therapy (IMRT). Regarding Radiation Therapy for Primary Cranial and Spinal Tumors and Neurologic Conditions, LCD L36711 provides that IMRT is covered for primary, metastatic or benign tumors of the central nervous system including the brain, the brain stem, and spinal cord and primary or metastatic tumors of the spine where the spinal cord tolerance may be exceeded with conventional treatment or where the spinal cord has previously been irradiated when LCD L36711 criteria is met. For additional information and eligibility, refer to Local Coverage Determination (LCD): Intensity Modulated Radiation Therapy (IMRT) (L36711). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36711&ver=18&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&.

Local Coverage Article: Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36711&ver=18&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&.


[RATIONALE: Surgical removal is recommended for most types of brain tumors in most locations, and their removal should be as complete as possible within the constraints of preservation of neurologic function. Treatment with photons has a major role in the treatment of patients with most tumor types, as evidenced in the European Organization for Research and Treatment of Cancer (EORTC-22845) and Medical Research Council (MRC-BR04) trials, and can increase the cure rate or prolong disease-free survival. IMRT may yield better dosimetry with sparing of normal brain tissue, especially in dose-escalated protocols.

I. High-grade gliomas


    Since the development of the Radiation Therapy Oncology Group-Recursive Partitioning Analysis (RTOG-RPA) risk classes for high-grade glioma, radiation therapy in combination with temozolomide (TMZ) has become standard care. While this combination has improved survival, the prognosis remains poor in the majority of individuals. In a phase III randomized study (Keime-Guibert, et al., 2007) of glioblastoma multiforme (GBM) and anaplastic astrocytoma (AA) in the New England Journal of Medicine (NEJM), post-operative external beam photon radiation therapy in the elderly statistically significantly improved the median survival compared to observation. Another phase III randomized study (Stupp et al., 2005) of high-grade gliomas revealed temozolomide plus external beam photon radiation therapy statistically significantly increased the survival rate compared to external beam photon radiation therapy alone. For high-grade brain tumors (WHO grade III-IV), typically 33 fractions of external beam photon radiation therapy are administered post-operatively with up to 5 coplanar or non-coplanar beams using 3DCRT or IMRT.

II. Low-grade gliomas (LGG)

    For low-grade brain tumors (WHO grade I-II), the role of postoperative radiotherapy (PORT) remains controversial. Cerebral low-grade gliomas (LGG) in adults are mostly composed of astrocytomas, oligodendrogliomas, and mixed oligoastrocytomas. An analysis using data from the EORTC 22844/22845 studies concluded that several factors portend a poor prognosis: age ≥ 40 years, astrocytoma histology, tumor size ≥ 6 cm, tumor crossing midline, and preoperative neurologic deficits. PORT may benefit patients with high-risk features. The EORTC trial 22844 did not revealed the presence of radiotherapeutic dose-response for patients with LGG for the two dose levels investigated with this conventional setup. A phase III prospective randomized trial (Shaw et al., 2002) of low- versus high-dose radiation therapy for adults with supratentorial low-grade astrocytoma, oligodendroglioma, and oligoastrocytoma found somewhat lower survival and slightly higher incidence of radiation necrosis in the high-dose RT arm. The most important prognostic factors for survival are histologic subtype, tumor size, and age. Recently updated results of RTOG 9802 showed significant improvement in progression-free survival (PFS) when patients also received chemotherapy with procarbazine/CCNU/vincristine (PCV). Median, 5-year, and 10-year PFS improved dramatically with the combined approach from 4.0 years to 10.4 years, from 44.1% to 61.2%, and from 20.9% to 50.5% respectively. For those patients who receive PORT, typically 30 fractions of external beam photon radiation therapy are administered with up to 5 coplanar or non-coplanar beams 3DCRT or IMRT.

III. Recurrent disease

    Currently the following options for salvage may be considered: re-resection, re-irradiation with either conventionally-fractionated doses, Stereotactic Radiation Therapy (SRT), Stereotactic Radiosurgery (SRS), interstitial brachytherapy, or single/poly-chemotherapy schedules including new dose-intensified or alternative treatment protocols employing targeted drugs. A recent review publication (Niyazi et al., 2011) concluded that these have only modest efficacy. The relative value of each approach compared to other options is unknown as well as it remains open which sequence of modalities should be chosen. Some individuals with recurrent disease may benefit from retreatment with radiotherapy, depending on prognostic factors including grade of tumor, age, and performance status. Other factors such as corticosteroid use may be important. A study (Wong et al., 1999) of several hundred patients retreated for recurrent gliomas at MD Anderson showed that 34 (9%) had complete or partial response, whereas 80 (21%) were alive and progression-free at 6 months (APF6). The median PFS was 10 weeks and median overall survival (OS) was 30 weeks. Histology was a robust prognostic factor across all outcomes. GBM patients had significantly poorer outcomes than AA patients did. The APF6 proportion was 15% for GBM and 31% for AA, whereas the median PFS was 9 weeks for GBM and 13 weeks for AA. Results were also significantly poorer for patients with more than two prior surgeries or chemotherapy regimens.

IV. Primary CNS lymphoma

    The incidence of primary CNS lymphoma dramatically increased in the last several decades, in part related to human immunodeficiency virus (HIV) infection. Primary CNS lymphoma (PCNSL) now accounts for 2 to 5% of CNS tumors. PCNSL occurs in the brain, leptomeninges, eye and spinal cord. Untreated PCNSL portends a dismal prognosis. Treatment is dependent on age, performance status, extent of disease, and HIV status. Surgery plays little role in the management of PCNSL. Continued investigation is underway to develop the optimal treatment strategy. Recommendations for individuals with good performance status include a high dose methotrexate regimen. For younger individuals, this is usually followed by radiation (24 to 45 Gy in standard fractionation). The timing of radiation is controversial; despite high response rates with a combination of the two modalities, increased neurotoxicity has been observed. Therefore, the recommendation for older (non-immune-suppressed) individuals is chemotherapy alone. For individuals with poor performance status single modality treatment is used, either radiation therapy or chemotherapy. Radiation is also indicated when there has been an incomplete or limited response to chemotherapy and in the setting of ocular or recurrent disease. For individuals with acquired immunodeficiency syndrome (AIDS) with low CD4 counts, treatment is usually palliative radiotherapy alone, 30 Gy in 10 fractions.

V. SRS

    A. Malignant tumors

      In 2005, the American Society for Radiation Oncology (ASTRO) published an evidenced-based review on the use of SRS for malignant glioma. ASTRO concluded that for individuals with malignant glioma, there is Level I-III evidence that the use of radiosurgery boost followed by external beam photon radiation therapy and bis-chlorethylnitrosourea (BCNU) does not confer benefit in terms of overall survival, local brain control, or quality of life as compared with external beam photon radiation therapy and BCNU. The use of radiosurgery boost is associated with increased toxicity. For an individual with malignant glioma, there is insufficient evidence regarding the benefits/harms of using SRS at the time progression or recurrence. There is also insufficient evidence regarding the benefits/harms in the use of stereotactic fractionated radiation therapy for individuals with newly diagnosed or progressive/recurrent malignant glioma. More recent publications have not provided evidence that would change these conclusions. While small, well-defined, unresectable low-grade gliomas are attractive targets for stereotactic irradiation, and fractionated stereotactic irradiation of these targets has the theoretical benefit of increased normal tissue sparing beyond that provided by the physical characteristics of SRS, no study has demonstrated its benefit compared to standard techniques. Published results from McGill (Roberge et al., 2006) which includes those of 241 patients treated in nine other institutional series conclude that data regarding the use of SRS is limited and, in their opinion, insufficient to claim a clear therapeutic advantage to SRS in the initial management of low-grade glioma. Several small single institution retrospective studies of higher-grade malignancies have been published between 2007 and 2012, and while they claim efficacy, there is no convincing evidence that these are better than standard therapies (Cuneo et al., 2012; Ernst-Stecken et al., 2007; Fields et al., 2012).

    B. Benign conditions

      The success and excellent safety margin of SRS in many other clinical situations has led to exploration of its use in benign tumors and neurologic conditions which are refractory to medical treatment and would otherwise require surgical procedures with significant morbidity and possible mortality. The condition to be treated must be causing severe symptoms or pose a serious threat to function or life expectancy and have an expected benefit of stabilizing or improving the clinical state. An individual with limited life expectancy and/or generally poor performance status (ECOG > 2) which are not expected to improve significantly with treatment should not be considered for SRS.

      The delivery of SRS may take 1 to 5 treatment sessions. By definition the performance of SRS must include:

      1. Patient immobilization with or without a frame

      2. Radiographic imaging such as computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) or other radiologic modalities to localize precisely the target area

      3. The use of computerized image guidance to insure precise treatment delivery. As per American Medical Association (AMA) coding guidelines, Image-Guided Radiation Therapy (IGRT) is included in the daily treatment delivery code and may not be billed separately

      4. Dedicated treatment planning and precise calculation with verification of setup and accuracy of all treatment parameters including but not limited to multiple isocenters, arcs, angles, number of beams (size and weight), isodose plans and calculations

      5. Accurate simulation and reproducibility of all treatment angles or arcs.]

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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Radiation Therapy for Primary Craniospinal Tumors and Neurologic Conditions
Radiation Treatment of Primary Cranial and Spinal Tumors and Neurologic Conditions
Radiation Treatment of Craniospinal Tumors - Primary and Neurologic Conditions
Craniospinal Tumors, Radiation Therapy
Craniospinal Tumors, Stereotactic Radiosurgery
Craniospinal Tumors, Stereotactic Radiotherapy
Stereotactic Radiosurgery of Craniospinal Tumors - Primary and Neurologic Conditions
Stereotactic Radiotherapy of Craniospinal Tumors - Primary and Neurologic Conditions
SRS, Craniospinal Tumors - Primary and Neurologic Conditions
SBRT, Craniospinal Tumors - Primary and Neurologic Conditions
Cranial Tumors, Radiation Treatment for
Spinal Tumors, Radiation Treatment for
Neurological Conditions, Radiation Treatment for

References:
Malignant tumors
  1. Buckner JC, Pugh SL, Shaw EG et al. Phase III study of radiation therapy (RT) with or without procarbazine, CCNU, and vincristine (PCV) in low-grade glioma: RTOG 9802 with Alliance, ECOG, and SWOG. J Clin Oncol. 2014 May 20; 32(15 suppl). Abstract 2000.
  2. Carson KA, Grossman SA, Fisher JD, et al. Prognostic factors for survival in adult patients with recurrent glioma enrolled onto the new approaches to brain tumor therapy CNS consortium phase I and II clinical trials. J Clin Oncol. 2007 Jun 20; 25(18):2601-2606.
  3. Cuneo KC, Vredenburgh JJ, Sampson JH, et al. Safety and efficacy of stereotactic radiosurgery and adjuvant bevacizumab in patients with recurrent malignant gliomas. Int J Radiat Oncol Biol Phys. 2012 Apr 1; 82(5):2018-2024.
  4. Ernst-Stecken A, Ganslandt O, Lambrecht U, et al. Survival and quality of life after hypofractionated stereotactic radiotherapy for recurrent malignant glioma. J Neurooncol. 2007 Feb; 81(3):287-294
  5. Fields EC, Damek D, Gaspar LE, et al. Phase I dose escalation trial of vandetanib with fractionated radiosurgery in patients with recurrent malignant gliomas. Int J Radiat Oncol Biol Phys. 2012 Jan 1; 82(1):51-57.
  6. Karim ABMF, Maat B, Hatlevoll R, et al. A randomized trial on dose-response in radiation therapy of low-grade cerebral glioma: European Organization for Research and Treatment of Cancer (EORTC) study 22844. Int J Radiat Oncol Biol Phys. 1996 Oct 1; 36(3):549-556.
  7. Keime-Guibert F, Chinot O, Taillandier L, et al. for the Association of French-Speaking Neuro-Oncologists. Radiotherapy for glioblastoma in the elderly. N Engl J Med. 2007 Apr 12; 356(15):1527-1535.
  8. Li J, Wang M, Won M, et al. Validation and simplification of the Radiation Therapy Oncology Group recursive partitioning analysis classification for glioblastoma. Int J Radiat Oncol Biol Phys. 2011 Nov 1; 81(3):623-630.
  9. Limentani SA, Asher A, Heafner M, et al. A phase I trial of surgery, Gliadel wafer implantation, and immediate postoperative carboplatin in combination with radiation therapy for primary anaplastic astrocytoma or glioblastoma multiforme. J Neurooncol. 2005 May; 72(3):241-244.
  10. MacDonald SM, Ahmad S, Kachris S, et al. Intensity modulated radiation therapy (IMRT) versus three-dimensional conformal radiation therapy (3DCRT) for the treatment of high grade glioma: a dosimetric comparison. J Appl Clin Med Phys. 2007 Apr 19; 8(2):47-60.
  11. National Comprehensive Cancer Network (NCCN) Guidelines Version 3.2019 – October 18, 2019. Central Nervous System Cancers. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Central Nervous System Cancers 3.2019. ©2019 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN®. To view the most recent and complete version of the NCCN Guidelines®, go online to NCCN.org.
  12. Niyazi M, Siefert A, Schwarz SB et al. Therapeutic options for recurrent malignant glioma. Radiother Oncol. 2011 Jan; 98(1):1-14.
  13. Roberge D, Souhami L, Olivier A, et al. Hypofractionated stereotactic radiotherapy for low grade glioma at McGill University: long-term follow-up. Technol Cancer Res Treat. 2006 Feb; 5(1):1-8.
  14. Ruden E, Reardon DA, Coan AD, et al. Exercise behavior, functional capacity, and survival in adults with malignant recurrent glioma. J Clin Oncol. 2011 Jul 20; 29(21):2918-2923.
  15. Shaw E, Arusell R, Scheithauer B, et al. Prospective randomized trial of low- versus high-dose radiation therapy in adults with supratentorial low-grade glioma: initial report of a North Central Cancer Treatment Group/Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group study. J Clin Oncol. 2002 May 1; 20(9):2267-76.
  16. Stupp R, Mason WP, van den Bent MJ, et al. for the European Organisation for Research and Treatment of Cancer Brain Tumor and Radiotherapy Groups; National Cancer Institute of Canada Clinical Trials Group. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med. 2005 Mar 10; 352(10):987-996.
  17. Suneja G, Alonso-Basanta M, Lustig R, et al. Postoperative radiation therapy for low-grade glioma. Cancer. 2012 Aug 1; 118(15):3735-3742.
  18. Tsao MN, Mehta MP, Whelan TJ, et al. The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for malignant glioma. Int J Radiat Oncol Biol Phys. 2005 Sep 1; 63(1):47-55.
  19. Wong ET, Hess KR, Gleason MJ, et al. Outcomes and prognostic factors in recurrent glioma patients enrolled onto phase II clinical trials. J Clin Oncol. 1999 Aug; 17(8):2572-2578.
  20. Wu W, Lamborn KR, Buckner JC, et al. Joint NCCTG and NABTC prognostic factors analysis for high-grade recurrent glioma. Neuro Oncol. 2010 Feb; 12(2):164-172.


Benign conditions
  1. Andrews DW, Suarez O, Goldman HW, et al. Stereotactic radiosurgery and fractionated stereotactic radiotherapy for the treatment of acoustic schwannomas: comparative observations of 125 patients treated at one institution. Int J Radiat Oncol Biol Phys. 2001 August 1; 50(5):1265-1278.
  2. Bledsoe JM, Link MJ, Stafford SL, Park PJ, Pollock BE. Radiosurgery for large-volume (> 10 cm3) benign meningiomas. J Neurosurg. 2010 May; 112(5):951-6. http://thejns.org/doi/abs/10.3171/2009.8.JNS09703.
  3. Castinetti F, Brue T. Gamma Knife radiosurgery in pituitary adenomas: Why, who, and how to treat? Discov Med. 2010 Aug; 10(51):107-111.
  4. Chang SD, Gibbs IC, Sakamoto GT, et al. Staged stereotactic irradiation for acoustic neuroma. Neurosurgery. 2005; 56(6):1254-1263.
  5. De Braganca KC, Packer RJ. Treatment options for medulloblastoma and CNS primitive neuroectodermal tumor (PNET). Curr Treat Options Neurol. 2013 Oct; 15(5):593-606.
  6. Elaimy AL, Arthurs BJ, Lamoreaux WT, et al. Gamma knife radiosurgery for movement disorders: A concise review of the literature. World J Surg Oncol. 2010 Jul 21; 8:61.
  7. Elaimy AL, Demakas JJ, Arthurs BJ, et al. Gamma knife radiosurgery for essential tremor: A case report and review of the literature. World J Surg Oncol. 2010 Mar 22; 8:20.
  8. Engenhart R, Kimmig B, Höver KH, et al. Stereotactic single high dose radiation therapy for benign tumors of the brain. Int J Radiat Oncol Biol Phys. 1989; 17(S1):95.
  9. Flickinger JC, Niranjan A. Stereotactic radiosurgery and radiotherapy. In Halperin EC, Wazer DE, Perez CA, and Brady LW, eds. Perez and Brady’s Principles and Practice of Radiation Oncology. 6th Edition. Philadelphia: Lippincott Williams & Wilkins, a Wolters Kluwer business, 2013:351-361.
  10. Hasagawa T, McInerney J, Kondziolka D, et al. Long-term results after stereotactic radiosurgery for patients with cavernous malformations. Neurosurgery. 2002; 50(6):1190-1198.
  11. Henson, CF, Goldman HW, Rosenwasser RH, et al. Glycerol rhizotomy versus gamma knife radiosurgery for the treatment of trigeminal neuralgia: An analysis of patients treated at one institution. Int J Radiat Oncol Biol Phys. 2005 Sep 1; 63(1):82-90.
  12. Kondziolka D. Gamma Knife thalamotomy for disabling tremor. Arch Neurol. 2002 Oct; 59(10):1660.
  13. Kondziolka D, Lunsford LD, Flickinger JC. Stereotactic radiosurgery for the treatment of trigeminal neuralgia. Clin J Pain. 2002 Jan-Feb; 18(1):42-47.
  14. Kondziolka D, Nathoo N, Flickinger JC, et al. Long-term results after radiosurgery for benign intracranial tumors. Neurosurgery. 2003 Oct; 53(4):815-822.
  15. MacNally SP, Rutherford SA, Ramsden RT, et al. Trigeminal schwannomas. Br J Neurosurg. 2008 Dec; 22(6):729-38.
  16. Malmstrom A, Gronberg ,BH, Marosi C, et al. Temozolomide versus 6-week radiotherapy versus hypofractionated radiotherapy in patients older than 60 years with glioblastoma: the Nordic randomised, phase 3 trial. Lancet Oncol. 2012 Sep; 13(9): 916-920.
  17. Onodera S, Aoyama H, Katoh N, et al. Long-term outcomes of fractionated stereotactic radiotherapy for intracranial skull base benign meningiomas in single institution. Jpn J Clin Oncol. 2011 Apr; 41(4):462-468.
  18. Portnow LH, Scott M, Morris CG, et al. Fractionated radiotherapy in the management of benign vascular tumors. Am J Clin Oncol. 2012 Dec; 35(6):557-561.
  19. Roa W, Brasher PMA, Bauman G, et al. Abbreviated course of radiation therapy in older patients with glioblastoma multiforme: A prospective randomized clinical trial. J Clin Onc. 2004 May 1; 22(9):1583-1588.
  20. Saraceni C, Ashman JB, Harrop JS. Extracranial radiosurgery--applications in the management of benign intradural spinal neoplasms. Neurosurg Rev. 2009 Apr; 32(2):133-141.
  21. Yap L, Kouyialis A, Varma TR. Stereotactic neurosurgery for disabling tremor in multiple sclerosis: thalamotomy or deep brain stimulation? Brit J Neurosurg. 2007 Aug; 21(4):349-54.
  22. Young RF, Jacques S, Mark R, et al. Gamma knife thalamotomy for treatment of tremor: long-term results. J Neurosurg. 2000 Dec; 93(Suppl 3):128-35.



Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*
    HCPCS

    * CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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    Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

    The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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