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Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12
Effective date
Nov 16, 2025
Identified
Jun 20, 2026
Summary
Excellus BlueCross BlueShield stereotactic radiosurgery and stereotactic body radiation therapy medical policy 6.01.12 has a current effective date of November 16, 2025. Its October 16, 2025 annual review removed life expectancy criteria from the policy criteria. SRS is considered medically appropriate for specified benign, brain and neurologic indications, SBRT is considered medically appropriate for specified extracranial cancers and oligometastatic disease, and SBRT is considered not medically necessary for indications including extrahepatic bile duct cancer, gallbladder cancer and chronic pain.
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What to do
Action · 6 steps
01Already effective November 16, 2025: Billing team: For SRS of intact brain metastases, confirm the record documents that all lesions can be encompassed in a single treatment plan, the ECOG performance status is 0-2, systemic disease is limited and under control or good systemic options are available, there is no leptomeningeal disease or the primary histology is not germ cell, small cell or lymphoma, and that either no more than four metastases are treated with each lesion under 4 cm (or 4 to 6 cm when the individual is not a surgical candidate, there is no mass effect and neurosurgery input is documented), or five to ten metastases are treated when the individual is not a surgical candidate, there is no mass effect and neurosurgery input is documented.
02Billing team: SBRT as a complete course of therapy must be completed in five fractions or less within a single episode of care.
03Billing team: For refractory movement disorders, the ordering provider must certify that the usual and customary treatments would not be successful in managing the member's condition.
04Billing team: SBRT is considered not medically necessary for metachronous oligoprogressive disease for any indication other than prostate cancer, extracranial repeat oligometastatic disease, extracranial induced oligometastatic disease, extrahepatic bile duct cancer, gallbladder cancer, chronic pain, adjuvant curative treatment of primary adrenocortical carcinoma, and planned neoadjuvant treatment of pancreatic cancer when the primary tumor is otherwise fully resectable, in the postoperative setting or in the palliative setting.
05Billing team: SBRT is considered investigational as an alternative to brachytherapy for cervical cancer and to induce abscopal effects.
06Billing team: Services are contract dependent; if a product does not cover a service, the medical policy criteria do not apply.
Codes mentioned
31626316273255349411494125587455876617966179761798617996180063620636217737177372773737743277435G0339G0340C11.0C11.9C22.0C22.9C25C34.00C34.92C41.0C41.2C49C53.0C53.9C61C64.1C64.9C65.1C65.9C70.0C70.9C71.0C71.9C72.0C72.1C75.1C75.3C78.7C79.00C79.02C79.31D01.5D18.02D32.0D32.9D33.0D33.4D35.0D35.4D37.6D42.0D42.9D43.0D43.4D44.3D44.5G20.0G25.0G50.0Q04.9Q06.9Q07.9Q27.9Q28.2Q28.3
Original notice
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy 6.01.12
excellusbcbs.com · Always check the source before changing claims.
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Related policy hubs
Excellus BlueCross BlueShield policiesNY policy changesRadiation OncologyOncologyNeurosurgeryCode 31626Code 31627Code 32553Code 49411Code 49412Code 55874Code 55876Code 61796Code 61797Code 61798Code 61799Code 61800Code 63620Code 63621Code 77371Code 77372Code 77373Code 77432Code 77435Code G0339Code G0340Code C11.0Code C11.9Code C22.0Code C22.9Code C25Code C34.00Code C34.92Code C41.0Code C41.2Code C49Code C53.0Code C53.9Code C61Code C64.1Code C64.9Code C65.1Code C65.9Code C70.0Code C70.9Code C71.0Code C71.9Code C72.0Code C72.1Code C75.1Code C75.3Code C78.7Code C79.00Code C79.02Code C79.31Code D01.5Code D18.02Code D32.0Code D32.9Code D33.0Code D33.4Code D35.0Code D35.4Code D37.6Code D42.0Code D42.9Code D43.0Code D43.4Code D44.3Code D44.5Code G20.0Code G25.0Code G50.0Code Q04.9Code Q06.9Code Q07.9Code Q27.9Code Q28.2Code Q28.3