Subject:
Radiation Therapy for Brain Metastases
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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Whole brain radiotherapy (WBRT):
External beam radiotherapy is accomplished with the use of a linear accelerator, that generates high energy x-rays that are directed at the involved organ. In the setting of metastatic disease to the brain, external beam radiation is most commonly directed at the whole brain (WBRT), to encompass the tumors well as brain tissue that is not apparently involved, under the assumption that these regions harbor cancer cells that were not detected on the pre-treatment imaging. WBRT is the most commonly utilized technique to treat brain metastases.
Partial brain radiotherapy:
Other external beam techniques can target just the tumor(s) that are apparent on the pre-treatment imaging scans, including stereotactic radiosurgery and 3-D conformal radiotherapy techniques, including intensity modulated radiotherapy (IMRT).
Stereotactic radiosurgery is a highly precise form of radiation therapy. Despite its name, stereotactic radiosurgery is a non-surgical procedure, and involves the use of highly focused x-rays to treat certain types of tumors, inoperable lesions, and as a post-operative treatment to eliminate any remaining tumor tissue.
The treatment involves the delivery of a single high-dose—or sometimes smaller, multiple doses of radiation, using multiple radiation beams or arcs that converge on the specific area of the brain where the tumor or other abnormality resides. Using an immobilization device that keeps the head completely still and three-dimensional computer-aided planning software, stereotactic radiosurgery minimizes the amount of radiation to healthy brain tissue.
Stereotactic radiosurgery is an important alternative to invasive surgery, especially for tumors and blood vessel abnormalities located deep within or close to vital areas of the brain. Radiosurgery is used to treat many types of brain tumors, both benign or malignant, and primary or metastatic. Additionally, radiosurgery is used to treat arteriovenous malformations (AVMs), a tangle of expanded blood vessels that disrupts normal blood flow in the brain and is the leading cause of stroke in young people.
Although stereotactic radiosurgery is often completed in a one-day session, physicians sometimes recommend a fractionated treatment, in which treatments are given over a period of days (maximum 5 fractions). This is referred to as stereotactic radiotherapy.
There are three basic forms of stereotactic radiosurgery, using different instruments and sources of radiation:
- Gamma Knife, which has 201 Cobalt sources to deliver highly focused gamma rays to areas of the brain.
- Linear accelerator (LINAC) machines, prevalent throughout the world, deliver high-energy x-ray photons or electrons in curving paths around the patient's head. The linear accelerator is adapted to perform radiosurgery on tumors in a single session or during multiple sessions, which is called fractionated stereotactic radiotherapy.
- Cyberknife - The CyberKnife system is an example of a radiosurgical device that is capable of performing both stereotactic radiosurgery and stereotactic radiotherapy (fractionated or staged). It features a compact linear accelerator, or radiation source, mounted on a flexible robotic arm. This system integrates image-guidance and robotic delivery of radiation. The image-guidance system allows the robotic arm to locate the tumor, in real time, throughout treatment and correct for small patient movements. Existing conventional systems rely on an external metal frame attached to the skull for target localization, which limits their application to lesions in the head. The CyberKnife instead uses internal reference points in the anatomy (skeletal landmarks or small implanted markers/fiducials) to enable frameless treatment of lesions anywhere in the body.
External beam 3-D conformal radiotherapy (3D-CRT) and intensity modulated radiotherapy (IMRT) refer to partial brain external beam techniques that treat just the tumor(s) that are clinically apparent on pre-treatment scans but where stereotactic radiosurgery is not available or appropriate due to tumor size, location, or other considerations. These techniques involve the use of multiple radiation “fields” that conform to the tumor(s), with (IMRT) or without (3-D CRT) computer-controlled alteration of the radiation intensity across each field.
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.)
I. Whole brain radiation therapy (WBRT)
A. Up to 15 fractions of WBRT using radiation planned with complex isodose technique is considered medically necessary. The use of 3D conformal or image-guided radiation therapy (IGRT) is not considered medically necessary.
II. Hippocampal-avoidance whole brain radiation therapy (HA-WBRT)
A. HA-WBRT is considered medically necessary using 10 fractions of intensity-modulated radiation therapy (IMRT) for individuals:
1. Who have a prognosis of at least 4 months and
2. Who have a Karnofsky Performance Status (KPS) of at least 70 or an Eastern Cooperative Oncology Group (ECOG) Performance Status of at least 2 and
3. Who have not had prior WBRT or external beam radiation to the brain and
4. Who do not have leptomeningeal disease and
5. Whose primary histology is not germ cell, small cell, lymphoma or unknown
III. Stereotactic radiosurgery (SRS)
A. Determination of medical necessity
1. SRS is medically necessary for individuals
a. Who have a Karmofsky Performance Score (KPS)of at least 70 and
b. Whose systemic disease is under control or good options for systemic treatment are available and
c. Who do not have leptomeningeal disease and
d. Whose primary histology is not germ cell, small cell, or lymphoma.
B. Treatment and retreatment
1. Initial treatment with SRS for brain metastases is medically necessary when the following conditions are met:
a. No lesion is greater than 5 cm and all lesions can be treated in a single treatment plan in a single fraction (for SRS) or 2 to 5 fractions (for fractionated SRS).
Note that all lesions present on imaging must be targeted as a single episode of care. If in order to accomplish this, more than 5 fractions are needed, each fraction must be billed as 3D conformal or IMRT, depending on the planning technique, as the definition of fractionated SRS is not met.
2. In an individual who has received prior SRS, retreatment with SRS is medically necessary when all of the following conditions are met:
a. No lesion is greater than 5 cm and all lesions can be treated in a single treatment plan in a single fraction (for SRS) or 2 to 5 fractions (for fractionated SRS).
b. The individual has not been treated with more than two episodes of SRS in the past 9 months
c. Note that all lesions present on imaging must be targeted as a single episode of care. If in order to accomplish this, more than 5 fractions are needed, each fraction must be billed as 3D conformal or IMRT, depending on the planning technqiue, as the definition of fractionated SRS is not met
d. Life expectancy > 6 months
e. Submission of recent consultation note and recent restaging studies.
3. In an individual who has received prior WBRT, SRS is medically necessary if the individual’s life expectancy is > 3 months
4. Post-operative SRS is considered medically necessary for treatment of:
a. A combination of up to 4 resected and unresected lesions that are individually < 4 cm in size.
Medicare Coverage:
There is no National Coverage Determination (NCD) for Radiation Therapy for Brain Metastases. 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 stereotactic radiosurgery (SRS), whole brain radiotherapy (WBRT), and image-guided therapy (IGRT). Therefore, Medicare Advantage Products will follow the Horizon Policy for stereotactic radiosurgery (SRS), whole brain radiotherapy (WBRT), and image-guided therapy (IGRT).
Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued a determination for Intensity-Modulated Radiation Therapy (IMRT). Regarding Radiation Therapy for Brain Metastases, LCD L36711 provides that IMRT is covered for primary, metastatic or benign tumors of the central nervous system including the brain and the brain stem 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&.
[INFORMATIONAL NOTE:
I. Whole brain radiation therapy (WBRT)
The median survival following the diagnosis of metastatic disease involving the brain is generally four to six months. Many patients develop brain metastases late in the course of their disease when progressive extracranial disease dictates survival. The clinical response rate, degree of response, and duration of response depend on the extent of tumor and the severity of initial neurologic deficits.
The use of alternative fractionation schedules during WBRT has been studied in patients with brain metastases and in those undergoing prophylactic cranial radiation (Borgelt et al., 1980; Le Péchoux et al, 2009; Murray et al., 1997; Wolfson et al., 2011). These studies have not shown any improvement in neurocognitive outcomes with alternative schedules. Shorter course regimens are appropriate for patients at increased risk of early death, such as those with a poor performance status and progressive systemic disease. Whole brain radiation using 30 Gy in 10 fractions is considered medically necessary in the treatment of brain metastases. For patients with an improved prognosis and few risk factors for early death, 37.5 Gy in 15 fractions can be considered medically necessary. In patients with a poor performance status, a shorter course of radiation using 20 Gy in 5 fractions should be utilized.
The use of whole brain radiation for individuals who are eligible for treatment with SRS to all brain metastases has changed. A meta-analysis in 2014 analyzed 5 randomized studies and found the addition of whole brain radiation with SRS vs. SRS or surgery alone decreased the risk of intra-cranial progression by 53% but did not improve overall survival (Soon, 2014). A recent large randomized study conducted by the Alliance group came to similar conclusions. This study randomized patients to SRS with whole brain radiation or SRS alone and found higher rates of cognitive deterioration in patients who received whole brain radiation (92% vs. 64%). Similarly, it found improved intracranial tumor rates (85% vs. 50% at one year) but no improvement in overall survival with whole brain radiation (HR 1.02, 95% CI 0.75-1.38) (Brown, 2016). Furthermore, in 2014, ASTRO released its second Choosing Wisely® recommendations, which stated “Don't routinely add adjuvant whole brain radiation therapy to stereotactic radiosurgery for limited brain metastases. (www.choosingwisely.org/astro-releases-second-list)”. Therefore, in individuals who can undergo routine surveillance, WBRT is not considered medically necessary as adjunctive therapy following treatment with SRS.
In patients who have undergone surgical resection, postoperative WBRT was associated with a three-fourths relative risk reduction in recurrence (absolute risk reduction 18%) and was associated with decreased risk of death from neurologic causes (Patchell et al., 1998). Therefore, postoperative whole brain radiotherapy can be recommended for individuals who undergo resection of a solitary metastasis and who have controlled extracranial disease.
Whole brain radiotherapy involves the use of two lateral opposed fields, with or without the use of custom blocking. Radiation planned using a complex isodose technique is considered medically necessary for the majority of patients requiring whole brain radiation therapy. Due to the palliative nature of the treatment, and dose delivered construction of a dose volume histogram is not medically necessary. In cases where the patient has received prior radiation 3D planning techniques will be considered.
One strategy to reduce the neurocognitive decline following whole brain radiation is the use of memantine. A single randomized study found a decrease in cognitive decline in patients who were started on memantine compared to observation, (hazard ratio 0.78, 95% CI 0.62 to 0.99).
Hippocampal avoidance whole brain IMRT has been studied as a strategy to decrease neurocognitive decline associated with whole brain radiation therapy. A phase II study RTOG 0933 examined whether hippocampal avoidance whole brain IMRT was associated with a decrease in neurocognitive decline. It found a mean decline in the Hopkins Verbal Learning Test of 7% at four months which compared favorably to historical comparison value of 30%. Overall survival was 6.8 months. There are limitations when comparing the results of this study to historical controls. For instance, the improved survival seen on 0933 could explain the improvement in neurocognitive decline. Furthermore, the delivery of hippocampal radiation is technically challenging as shown in an analysis that found 24% of cases submitted to RTOG 0933 had unacceptable deviations when the contours were submitted for pretreatment review (Gondi, 2015).
NRG CC001 is a randomized phase III trial of 518 patients with brain metastases 5 mm outside of the hippocampus and KPS ≥ 70 who were randomized to whole brain radiation therapy (WBRT) or to hippocampal avoidance whole-brain radiotherapy (HA-WBRT). Both arms received memantine and were treated to 30 Gy. The primary endpoint was time to neurocognitive failure.
At a median follow up of 7.9 months, the time to cognitive failure was significantly lower in those receiving HA-WBRT (HR of 0.745, p=0.02). Though there was no difference at 2 months between the arms, the HA-WBRT arm was significantly less likely to have a deterioration in HVLT-R total recall and delayed recognition at 6 months (16.4% vs. 33.3%, p=0.02). Further, those receiving HA-WBRT reported significantly less fatigue, less difficulty with remembering things, and less difficulty with speaking. There was no difference in intracranial progression free survival or overall survival.
The authors note that the “benefit of HA-WBRT emerges robustly with ≥ 4 months follow-up” and that “it seems reasonable to forego HA during WBRT in patients with survival expected to be < 4 months.” NCCN Guidelines® also state that “for patients with a better prognosis (4 months or greater), consider hippocampal-sparing WBRT.” As such, HA-WBRT is considered medically necessary in individuals with a life expectancy of at least 4 months who also meet criteria for entrance into the trial (i.e. no leptomeningeal disease, known primary histology excluding lymphoma, small cell and germ cell).
II. Stereotactic radiosurgery (SRS)
Selection criteria for radiosurgery are similar to those for surgical resection, i.e. individuals with solitary metastases, tumor size, tumor location, good performance status, and limited or responsive extracranial disease (Andrews, 2004; Kocher, 2011; Soon, 2014; Yamamoto, 2014). In tumors, up to 3 cm in size, radiosurgery is associated with a local control of approximately 70% at one year (Kocher, 2011). A recent prospective nonrandomized study revealed radiosurgery could be utilized in the treatment of up to 10 brain metastases with similar efficacy and no increase in toxicity as long as the cumulative volume < 15 mL.
Given the available data, radiosurgery is considered medically necessary in the initial management of individuals with brain metastases who meet the following conditions: 1) no lesion is greater than 5 cm, 2) the individual has a KPS > 70, 3) systemic disease is under control or good options for systemic treatment are available, 4) there is no leptomeningeal disease, 5) primary histology is not germ cell, small cell, or lymphoma, and 6) all lesions can be treated in a single fraction (for SRS) or up to 5 fractions (for fractionated SRS).
According to guidance published by ASTRO, CPT instructions for CPT® 77373 “Stereotactic body radiation therapy (SBRT), treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions…” and include the possibility of treating multiple sites of disease in one treatment course. Further, “…for single fraction cranial lesion(s), see CPT® 77371 and CPT® 77372.” Therefore, if the sum of the treatment days for all of the sites treated during a single course of therapy exceeds five, it is not appropriate to charge CPT® 77373 for SBRT delivery.
Following radiosurgery alone, approximately 25 to 50% of patients will develop new metastases within the first year (Ayala-Peacock, 2014; Gorovets, 2017). Treatment options for new metastases include further radiosurgery or whole brain radiation therapy. Factors predicting for recurrences within the brain include age, histology, increasing number of brain metastases, and increasing extracranial disease burden (Gorovets, 2017). The primary drawback with the use of radiosurgery upfront is the increased risk of distant failure in the brain (Kotecha, 2017). Individuals who present with early and extensive distant failure in the brain and those with limited survival are better treated with whole brain radiation therapy. About 40% of individuals will require whole brain radiation within 6 months of initial treatment with radiosurgery. In individuals who do experience further recurrence in the brain following radiosurgery it is critical to risk stratify this cohort to determine who will benefit from further radiosurgery vs. whole brain radiation (Gorovets, 2017).
Therefore, further treatment with radiosurgery, in a previously treated individual will be considered medically necessary in those who meet the following conditions: 1) new lesions (no lesion is greater than 5 cm) are present, 2) life expectancy is > 6 months, 3) the individual has a KPS > 70, 4) systemic disease is under control or good options for systemic treatment are available, 5) there is no leptomeningeal disease, 6) primary histology is not germ cell, small cell, or lymphoma, 7) all lesions can be treated in a single treatment plan with a single fraction (for SRS) or up to 5 fractions (for fractionated SRS), and 8) the individual has not been treated with more than two episodes of radiosurgery in the past 9 months.
In addition, submission of the consultation note and recent restaging studies will be required for review to verify that the individual’s systemic disease is controlled, life expectancy, history of previous treatments, and performance status.
A. Postoperative SRS
1. MD Anderson Cancer Center (MDACC)
Mahajan et al. (2017) reported a phase III randomized trial (NCT00950001) of 132 patients with 1 to 3 completely resected brain metastases treated with postoperative SRS or observation. Patients were excluded if the tumor cavity was greater than 4 cm, the unresected brain metastases were no greater than 3 cm, there was prior history of brain radiation, presence of leptomeningeal disease, a prior history of resection of any brain metastases, incomplete resection, poor performance status (KPS < 70), and small cell lung malignancies (1 vs. 2 to 3), histology (melanoma vs. other), and preoperative tumor size (< 3 cm vs. > 3 cm).
At 12 months, the use of SRS was associated with improved freedom from local recurrence (73% vs. 43% in observation, p = 0.015) with no statistically significant increase in distant brain metastases or time to whole brain radiation. Median overall survival (OS) was similar (17 months for the SRS group vs. 18 months for the observation group). In a post-hoc analysis, patients with an initial tumor diameter of 2.5 cm or less was associated with a 91% 12-month freedom from local recurrence rate, whereas those with a tumor > 2.5 cm had a local control rate of 40 to 46%. In multivariate analysis, predictors for time to local recurrence were SRS and metastases size. For overall survival, only stable disease (compared to progressive disease) was a significant predictor.
2. N107C/CEC.3
Brown et al. (2017) reported on a phase III trial randomizing patients to SRS or WBRT to the resection cavity after resection (total or subtotal) of brain metastases. Patients eligible included those with one resected brain metastasis (with a resection cavity under 5 cm) with up to an additional 3 unresected metastases (each under 3 cm). It is noted that in both groups, SRS was given to the unresected metastases. Patients were excluded if there was prior cranial radiation; leptomeningeal metastases; lesions within 5 mm of the optic chiasm or within the brain stem; or germ cell, small-cell, or lymphoma histologies. Patients were stratified according to age, duration of extracranial disease control, number of brain metastases, histology, and diameter of resection cavity and treatment center. The primary endpoints were cognitive deterioration free survival (CDFS) and OS.
One hundred ninety-four (194) patients were included in the study with a median follow up of 11.1 months. It is noted that of the 98 patients assigned to SRS, 5 did not receive treatment, 1 did not have baseline testing done, 11 died prior to 3 months, 20 did not complete cognitive assessment at 3 months, 13 died between 3 and 6 months, 1 was lost to follow up between 3 and 6 months, and 16 did not complete cognitive assessment at 6 months.
The authors reported that the median CDFS was longer following SRS than WBRT (3.7 months vs. 3.0 months, p < 0.0001). When they conducted a stratified analysis, the median CDFS was longer following SRS than WBRT (3.7 months vs. 3.1 months, p < 0.0001).
Cognitive deterioration at 6 months was lower in the SRS group vs. WBRT (52% vs. 85%). However, about half of the patients enrolled (54 [SRS] and 48 [WBRT]) were available for analysis at this time.
Median OS was not statistically different between the two groups (12.2 months for SRS vs. 11.6 months for WBRT). It is noted, however, that brain metastases was the cause of death in 87% of SRS patients vs. 73.1% in those receiving WBRT (p value not provided).
Local control and distant brain control were worse in the SRS group. For example, surgical bed control was significantly worse with SRS at 6- and 12-months (80.4% and 60.5% vs. 87.1% and 80.6% respectively). Local control was significantly worse with SRS at 3-, 6-, and 12-months (84.7%, 69.4%, and 61.8% vs. 96.7%, 92.5%, and 87.1% respectively). Distant brain control was significantly worse with SRS at 6- and 12-months (72.1% and 64.7% vs. 94.6% and 89.2% respectively). SRS was associated with a shorter time to intracranial progression as compared to WBRT (6.4 months vs. 27.5 months, p < 0.0001). Twenty percent (20%) of patients in the SRS group received WBRT as salvage therapy.
With respect to quality of life measurements, a clinically significant improvement was noted more frequently in the SRS group as compared to the WBRT group for physical well-being at 6 months. On the other hand, there was no difference in functional independence change from baseline at 6 months. The authors conclude that ”SRS in the postoperative setting is a viable treatment option…and should be considered one of the standards of care as a less toxic alternative to WBRT.”]
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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 Brain Metastases
Radiation Treatment of Brain Metastases
Brain Metastases, Radiation Treatment
Radiotherapy of Brain Metastases
Brain Metastases, Stereotactic Radiosurgery
Stereotactic Radiosurgery, Brain Metastases
SRS, Brain Metastases
References:
1. American Society for Radiation Oncology (ASTRO) Stereotactic Body Radiation Therapy (SBRT) Model Policy. 2014.
2. American Society for Radiation Oncology (ASTRO) Stereotactic Radiosurgery (SRS) Model Coverage Policy. Final Approval: 1-14-11. Updated 7-25-11.
3. Andrews DW, Scott CB, Sperduto PW, et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of RTOG 9508 randomized trial. Lancet. 2004 May 22; 363(9422):1665-1672.
4. ASTRO releases second list of five radiation oncology treatments to question, as part of national Choosing Wisely® campaign.
5. ASTRO 2014 Choosing Wisely List.
6. Ayala-Peacock DN, Peiffer AM, Lucas JT, et al. A nomogram for predicting distant brain failure in patients treated with gamma knife stereotactic radiosurgery without whole brain radiotherapy. Neuro Oncol. 2014 Sep; 16(9):1283-1288.
7. Borgelt B, Gelber R, Kramer S, et al. The palliation of brain metastases: final results of the first two studies by the Radiation Therapy Oncology Group. Int J Radiat Oncol Biol Phys. 1980 Jan; 6(1):1-9.
8. Brennan C, Yang TJ, Hilden P, et al. A phase 2 trial of stereotactic radiosurgery boost after surgical resection for brain metastases. Int J Radiat Oncol Biol Phys. 2014 Jan 1; 88(1):130-136.
9. Brown PD, Ballman KV, Cerham JH, et al. Postoperative stereotactic radiosurgery compare with whole brain radiotherapy for resected metastatic brain disease (NCCTG N107C/CEC-3); a multicenter, randomised controlled, phase 3 trial. Lancet Oncol. 2017 Aug;18(8):1049-1060.
10. Brown PD, Gondini V, Puch S, et al. Hippocampal Avoidance During Whole-Brain Radiotherapy Plus Memantine for Patients With Brain Metastases: Phase III Trial NRG Oncology CC001. J Clin Oncol. 2020 Feb 14;38. doi: 10.1200/JCO.19.02767.
11. Brown PD, Jaeckel K, Ballman KV, et al. Effect of radiosurgery alone vs. radiosurgery with whole brain radiation therapy on cognitive function in patients with 1 to 3 brain metastases: a randomized clinical trial. JAMA. 2016 Jul 26; 316(4):401-409.
12. Gondi V, Cui Y, Mehta MP, et al. Real-time pretreatment review limits unacceptable deviations on a cooperative group radiation therapy technique trial: quality assurance results of RTOG 0933. Int J Radiat Oncol Biol Phys. 2015 Mar 1; 91(3):564-570.
13. Gondi V, Pugh SL, Tome WA, et al. Preservation of memory with conformal avoidance of the hippocampal neural stem-cell compartment during whole-brain radiotherapy for brain metastases (RTOG 0933): a phase II multi-institutional trial. J Clin Oncol. 2014 Dec 1;32(34):3810-3816.
14. Gondi V, Pugh S, Brown PD, et al. NCOG-01. Preservation of Neurocognitive Function (NCF) With Hippocampal Avoidance during Whole-Brain Radiotherapy (WBRT) for Brain Metastases: Preliminary Results of Phase III Trial NRG Oncology CC001. Neuro Oncol. 2018; 20(Suppl 6): vi172.
15. Gorovets D, Ayala-Peacock D, Tybor DJ, et al. Multi-institutional nomogram predicting survival free from salvage whole brain radiation after radiosurgery in patients with brain metastases. Int J Radiat Oncol Biol Phys. 2017 Feb 1; 97(2):246-253.
16. Jensen CA, Chan MD, McCoy TP, et al. Cavity-directed radiosurgery as adjuvant therapy after resection of a brain metastasis. J Neurosurg. 2011 Jun; 114(6):1585-1591.
17. Kelly PJ, Lin YP, Yu AY, et al. Stereotactic irradiation of the postoperative resection cavity for brain metastasis: a frameless linear accelerator-based case series and review of the technique. Int J Radiat Oncol Biol Phys. 2012 Jan1; 82(1):95-101.
18. Kocher M, Soffietti R, Abacioglu U, et al. Adjuvant whole-brain radiotherapy versus observation after radiosurgery or surgical resection of one to three cerebral metastases: results of the EORTC 22952-26001 study. J Clin Oncol. 2011 Jan10; 29(2):134-141.
19. Kotecha R, Damico N, Miller JA, et al. Three or more courses of stereotactic radiosurgery for patients with multiple recurrent brain metastases. Neurosurgery. 2017 Feb 7.
20. Le Péchoux C, Dunant A, Senan S, et al. Standard-dose versus higher-dose prophylactic cranial irradiation (PCI) in patients with limited-stage small-cell lung cancer in complete remission after chemotherapy and thoracic radiotherapy (PCI 99-01, ERTC 22003-08004, RTOG 0212, and IFCT 99-10): a randomized clinical trial. Lancet Oncol. 2009 May; 10(5):467-474.
21. Liang X, Ni L, Hu W, et al. A planning study of simultaneous integrated boost with forward IMRT for multiple brain metastases. Med Dosim. 2013 Summer; 38(2):115-116.
22. Mahajan A, Ahmed S, McAleer MF, et al. Post-operataive stereotactic radiosurgery versus observation for completely resected brain metastases: a single centre, randomised, controlled, phase 3 trial. Lancet Oncol. 2017 Aug 1;18(8):1040-1048.
23. Murray KJ, Scott C, Greenberg HM, et al. A randomized phase III study of accelerated hyperfractionation vs. standard treatment in patients with unresected brain metastases. A report of the Radiation Therapy Oncology Group (RTOG) 9104. Int J Radiat Oncol Biol Phys. 1997 Oct; 39(3):571-574.
24. 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.
25. Patchell RA, Tibbs PA, Regine WF, et al. Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA. 1998; 280(17):1485-1489.
26. Shaw E, Scott C, Souhami L, et al. Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and brain metastases: final report of RTOG protocol 90-05. Int J Radiat Oncol Biol Phys. 2000 May 1; 47(2):291-298.
27. Shuh, JH. Hippocampal-Avoidance Whole-Brain Radiation Therapy: A New Standard for Patients With Brain Metastases? [Editorial]. J Clin Oncol. 2014 Dec 1;32(34):3789-3791. doi: 10.1200/JCO.2014.58.4367.
28. Soon YY, Tham IW, Lim KH, et al. Surgery or radiosurgery plus whole brain radiotherapy versus surgery or radiosurgery alone for brain metastases. Cochrane Database Syst Rev. 2014 Mar 1; (3):1-69.
29. Sperduto PW, Kased N, Roberg D, et al. Summary report of the graded prognostic assessment: an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases. J Clin Oncol. 2012 Feb;30(4):419-425.
30. Sperduto PW, Shanley R, Luo X, et al. Secondary analysis of RTOG 9508, a phase 3 randomized trial of whole-brain radiation therapy versus WBRT plus stereotactic radiosurgery in patients with 1-3 brain metastases; poststratified by the graded prognostic assessment (GPA). Int J Radiat Oncol Biol Phys. 2014 Nov 1;90(3):526-31.
31. Sperduto PW, Yang TJ, Beal K, et al. Estimating survival in patients with lung cancer and brain metastases: an update of the graded prognostic assessment for lung cancer using molecular markers (Lung-molGPA). JAMA Oncol. 2017 Jun 1;3(6):827-831.
32. Weiner JP. Neurocognitive Outcomes for Patients With Brain Metastasis in the Modern Era: Benefit of Treatment With Hippocampal Avoidance Whole-Brain Radiotherapy Plus Memantine. [Editorial]. J Clin Oncol. 2020 Feb 14; doi: https://doi.org/10.1200/JCO.19.03359.
33. Wolfson AH, Bae K, Komaki R, et al. Primary analysis of a phase II randomized trial Radiation Therapy Oncology Group (RTOG) 0212: impact of different total doses and schedules of prophylactic cranial irradiation on chronic neurotoxicity and quality of life for patients with limited-disease small-cell cancer. Int J Radiat Oncol Biol Phys. 2011 Sep 1;81(1): 77-84.
34. Yamamoto M, Serizawa T, Shuto T, et al. Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet Oncol. 2014 Apr; 15(4):387-395.
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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