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Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

Blue Cross & Blue Shield of Mississippi·MS · Oncology, Neurosurgery, Radiology +1 more·Medical Policy
Effective date
Not stated
We identified it
Jun 20, 2026
Days to comply

Summary

This policy establishes coverage criteria for Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT) for specific medical conditions. The policy defines when these advanced radiation therapy techniques are considered medically necessary versus investigational.

Action Required

Action needed
Immediately: Billing and clinical teams must review current SRS and SBRT cases to ensure they meet the specific medical necessity criteria outlined in this policy. Update prior authorization requests to reference the covered indications (arteriovenous malformations, trigeminal neuralgia, brain metastases, spinal tumors, stage T1/T2a NSCLC, liver tumors, renal cell carcinoma, and oligometastases). Flag investigational uses including prostate cancer, pancreatic adenocarcinoma, and small cell lung cancer as non-covered. Claims for non-covered indications will be denied.