CPT 61796, 61797, 61798 - Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy: Cranial Lesions

The adjective “Stereotactic” describes a procedure during which a target lesion is localized relative to a fixed three-dimensional reference system such as a rigid head frame affixed to a patient, fixed bony landmarks, a system of implanted fiducial markers or other similar system. This type of localization procedure allows physicians to perform image-guided procedures with a high degree of anatomic accuracy and precision. 

Stereotactic Body Radiation Therapy (SBRT) 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. SBRT 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. Technologies that are used to perform SRS include linear accelerators, particle beam accelerators and multi-source Cobalt-60 units. In order to enhance precision, various devices may incorporate robotics and real-time 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. When utilized in the later situation (two to five fractions), therapy is considered SBRT.

Regardless of the number of sessions, both SBRT and SRS procedures for cranial lesions include the following components:

• Position stabilization (attachment of a frame or frameless).
• Imaging for localization (Computed Tomography (CT), Magnetic Resonance Imaging (MRI), angiography, Positron Emission Tomography (PET), etc.).
• Computer-assisted tumor localization (i.e., image guidance).
• Treatment planning – number of isocenters, number, placement and length of arcs or angles, beam size and weight, etc.
• Isodose distributions, dosage prescription and calculation.
• Setup and accuracy verification testing.
• Simulation of prescribed arcs or fixed portals.
• Radiation treatment delivery.

Indications for SRS/SBRT of cranial lesions:

• Primary central nervous system malignancies, generally under 5 cm.
• Primary and secondary tumors involving the brain or spine parenchyma, meninges/dura or immediately adjacent boney structures.
• Benign brain tumors and spinal tumors such as meningiomas, acoustic neuromas, pituitary adenomas and pineal cytomas.
• Cranial arteriovenous malformations and hemangiomas.
• 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.
• 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).
• 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.
• Relapse in a previously irradiated cranial or spinal field where the additional stereotactic precision is required to avoid unacceptable vital tissue radiation.

Limitations:

• Medicare would not expect to provide payment for the following:
  • Treatment for anything other than a severe symptom or serious threat to life or critical functions, not responsive or reasonably amenable to another therapy.
  • Treatment unlikely to result in functional improvement or clinically meaningful disease stabilization, not otherwise achievable.
  • Patients with wide-spread cerebral or extra-cranial metastases.
  • Patients with poor performance status (Karnofsky Performance Status less than 40), – see Karnofsky Performance Status below.
  • A claim for stereotactic cingulotomy as a means of psychotherapy, considered investigational, per Medicare National Coverage Determinations (NCD) Manual, IOM Pub. 100-03, Chapter 1, Part 2, Section 160.4 (formerly CIM 35-84).

For ICD-9-CM diagnosis code 333.1, 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

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 85X

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances, Revenue Codes are purely advisory; unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.

0333, 0360

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
61796©	Srs, cranial lesion simple
61797©	Srs, cran les simple, addl
61798©	Srs, cranial lesion complex
61799©	Srs, cran les complex, addl
61800©	Apply srs headframe add-on
63620©	Srs, spinal lesion
63621©	Srs, spinal lesion, addl
77371©	Srs, multisource
77372©	Srs, linear based
77373©	Sbrt delivery*
	*Use for treatment of cranial lesion, two to five fractions.
77432©	Stereotactic radiation trmt
77435©	Sbrt management*
	*Use for cranial lesion treatment management, two to five 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 five sessions per course of treatment

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339 and G0340:

Covered for:

147.0–147.3	Malignant neoplasm of nasopharynx
147.8–147.9	Malignant neoplasm of nasopharynx
160.0–160.5	Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
160.8–160.9	Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
190.0–190.9	Malignant neoplasm of eye
191.0–191.9	Malignant neoplasm of brain
192.0–192.3	Malignant neoplasm of other and unspecified parts of nervous system
194.3–194.4	Malignant neoplasm of other endocrine glands and related structures
194.6	Aortic body and other paraganglia
198.3–198.5*	Secondary malignant neoplasm of other sites
198.89*	Other (Other specified sites)
225.0–225.4	Benign neoplasm of brain and other parts of nervous system
227.3–227.4	Benign neoplasm of other endocrine glands and related structures
227.6	Benign neoplasm of aortic body and other paraganglia
228.02	Of intracranial structures (Hemangioma any site)
234.8*	Carcinoma in situ of other specified sites
237.0–237.1	Neoplasm of uncertain behavior of endocrine glands and nervous system
237.3	Paraganglia
237.5–237.6*	Neoplasm of uncertain behavior of endocrine glands and nervous system
239.6–239.7*	Neoplasms of unspecific nature
239.81	Neoplasms of unspecified nature, retina and choroid
239.89	Neoplasms of unspecified nature, other specified sites
332.0	Paralysis agitans
333.1	Essential and other specified forms of tremor
	Note: Code 333.1 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.
345.11	Generalized convulsive epilepsy
345.3	Grand mal status epileptic
345.91	Epilepsy unspecified with intractable epilepsy
350.1	Trigeminal neuralgia
350.8–350.9	Trigeminal nerve disorders
351.0–351.1	Facial nerve disorders
351.8–351.9	Facial nerve disorders
352.0–352.6*	Disorders of cranial nerve
352.9*	Unspecific disorder of cranial nerves
747.81*	Congenial anomalies of cerebrovascular system
990	Effects of radiation unspecified
	Note: Code 333.1 may only be used where prior radiation therapy to the site is the governing factor necessitating SRS in lieu of other radiotherapy. An ICD-9-CM code for the anatomic diagnosis must also be used.

* ICD-9-CM codes 198.4, 198.5, 198.89, 234.8, 237.5, 237.6, 239.6, 239.7, 239.81, 239.89, 333.1, 352.0, 352.1, 352.2, 352.3, 352.4, 352.5, 352.6, 352.9 and 747.81 are all limited to use for lesions occurring either above the neck or in the spine.
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.