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A.6.01.10
Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) are 3-dimensional conformal radiotherapy methods that deliver highly focused, convergent radiotherapy beams on a target that is defined with 3-dimensional imaging techniques with the ability to spare adjacent radiosensitive structures. Stereotactic radiosurgery primarily refers to such radiotherapy applied to intracranial lesions. Stereotactic body radiotherapy refers to therapy generally applied to other areas of the body. Both techniques differ from conventional external-beam radiotherapy, which involves exposing large areas of tissue to relatively broad fields of radiation over multiple sessions.
Background
In the United States, certain racial/ethnic groups continue to be at an increased risk of developing or dying from particular cancers. Black men have the highest rate of new cancer diagnoses and Black men and women experience the highest rate of cancer-related death. American Indians and Alaska Natives are disproportionally affected by kidney cancer and also have higher death rates from this cancer when compared to other racial/ethnic groups.
Studies have demonstrated that there are socioeconomic disparities with regard to access to radiation therapy, particularly for patients in ethnic minority groups and those living in rural areas.
Conformal Radiotherapy
Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) are techniques that use highly focused, conformal radiation beams to treat both neoplastic and non-neoplastic conditions. Although SRS and SBRT may be completed with one session (single-fraction), SRS typically refers to a single-session procedure to ablate the target lesion. However, either technique may require additional sessions (typically not >5) over a course of days, referred to as fractionated radiotherapy.
Platforms available for SRS and SBRT are distinguished by their source of radiation; these platforms include gamma radiation from cobalt 60 sources; high-energy photons from linear accelerator (LINAC) systems; and particle beams (eg, protons). Particle beam therapy is not covered in this policy.
SRS and SBRT have been used for a range of malignant and nonmalignant conditions. A comprehensive assessment that encompasses all potential uses is beyond the scope of this policy.
Several devices that use cobalt 60 radiation (gamma-ray devices) for SRS have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. The most commonly used gamma-ray device, approved in 1999, is the Gamma Knife® (Elekta; product code IWB), which is a fixed device used only for intracranial lesions. Gamma-ray emitting devices that use cobalt 60 degradation are also regulated through the U.S. Nuclear Regulatory Commission.
A number of LINAC movable platforms that generate high-energy photons have been cleared for marketing by the FDA through the 510(k) process. Examples include the Novalis Tx® (Novalis); the TrueBeam STx (Varian Medical Systems; approved 2012; FDA product code IYE); and the CyberKnife® Robotic Radiosurgery System (Accuray; approved 1998; FDA product code MUJ). LINAC-based devices may be used for intracranial and extracranial lesions.
This policy addresses the use of stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) delivered by gamma-ray or high-energy photons generated by a linear accelerator (LINAC) unit. The use of charged-particle (proton on helium ion) radiotherapies is addressed separately in the Charged-Particle (Proton or Helium Ion) Radiotherapy for Neoplastic Conditions medical policy.
Stereotactic radiosurgery using Gamma-ray radiosurgery (Gamma Knife®) or Linear-accelerator radiosurgery (LINAC, CyberKnife®) unit may be considered medically necessary for the following indications:
Arteriovenous malformations;
Trigeminal neuralgia refractory to medical management;
Mesial temporal lobe epilepsy refractory to medical management when standard alternative surgery is not an option;
Acoustic neuromas;
Pituitary adenomas;
Nonresectable, residual, or recurrent meningiomas;
Craniopharyngiomas;
Glomus jugulare tumors;
Malignant neoplastic intracranial lesion(s) (eg, gliomas, astrocytomas);
Solitary or multiple brain metastases in individuals having good performance status and no active systemic disease (defined as extracranial disease that is stable or in remission) (see Policy Guidelines section);
Primary malignancies of the CNS, including but not limited to high-grade gliomas (initial treatment or treatment of recurrence)
Uveal melanoma.
Stereotactic Body Radiotherapy (SBRT) may be considered medically necessary for the following indications:
Primary or metastatic spinal or vertebral body tumors in individuals who have received prior spinal radiotherapy;
Spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma, and sarcoma);
Individuals with stage T1 or T2a non-small cell lung cancer (not larger than 5 cm) showing no nodal or distant disease and who are not candidates for surgical resection;
Primary or metastatic tumors of the liver as an alternative locoregional treatment for individuals with inoperable primary or metastatic lesions;
Primary renal cell carcinoma in individuals who are not good surgical candidates or who have metastatic renal cell carcinoma;
Oligometastases involving the lung, adrenal glands, and bone (other than spine or vertebral body).
When stereotactic radiosurgery or stereotactic body radiotherapy are performed using fractionation (defined in the Policy Guidelines) for the medically necessary indications described above, it may be considered medically necessary.
Stereotactic radiosurgery is investigational for other applications including, but not limited to, the treatment of functional disorders (other than trigeminal neuralgia), including chronic pain and tremor.
Stereotactic body radiotherapy is investigational for prostate cancer, pancreatic adenocarcinoma, small cell lung cancer, and other conditions, except as outlined in the policy statements above.
Federal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Radiation Source
This policy addresses the use of stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) delivered by gamma-ray or high-energy photons generated by a linear accelerator (LINAC) unit. The use of charged-particle (proton or helium ion) radiotherapies is not addressed.
Number of Lesions
A 1995 TEC Assessment on SRS for multiple brain metastases found that the evidence was sufficient to show that radiosurgery improved health outcomes for up to 3 metastases in the presence of good performance status and no active systemic disease. While evidence continues to demonstrate the importance of good performance status and absence of active systemic disease, it appears that the number of metastases may not be as predictive of outcome. Thus, individuals with more than 3 metastases who otherwise have good performance status and no evidence of active systemic disease may still benefit from SRS.
Many individuals with brain metastases can either receive whole-brain radiotherapy along with SRS, or the whole-brain radiotherapy may be delayed for use as salvage therapy for recurrent intracranial disease.
Fractionation
Fractionated stereotactic radiotherapy refers to when SRS or SBRT is performed more than once on a specific site.
SBRT is commonly delivered over 3 to 5 fractions.
SRS is most often single-fraction treatment; however, multiple fractions may be necessary when lesions are near critical structures.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
9/1992: Approved by Medical Policy Advisory Committee (MPAC)
9/1994: Reviewed and updated by MPAC
10/1996: Reviewed and updated by MPAC
2/2001: Reviewed by MPAC; Proton beam therapy for prostate cancer considered investigational
4/3/2001: Code Reference updated
5/8/2001: Proton Beam is medically necessary for early stage, surgically inoperable non-small cell lung cancer.
9/5/2001: Trigeminal Neuralgia refractory to medical management added as covered indication
2/13/2002: Investigational definition added
3/5/2002: Prior authorization added
3/12/2002: New 2002 codes added
5/8/2002: Type of Service and Place of Service deleted
9/20/2002: Policy reviewed, Hayes report number added
12/4/2002: Hayes report number deleted
12/11/2002: HCPCS S8030 added
1/17/2003: Policy section updated
3/7/2003: Code Reference section updated
8/20/2003: ICD-9 procedure code range 92.30-92.39 listed separately, ICD-9 diagnosis code ranges 162.0-162.9, 191.0-191.9 listed separately
6/3/2004: HCPCS G0338, G0339, G0340 added to covered codes
2/11/2005: CPT code 61795 Note: "It is appropriate for providers to report 61795 when performed in conjunction with ENT, head, and neck procedures, including functional endoscopic sinus surgeries (FESS). Some examples would include those procedures described by codes 31254-31256, 31267, 31276, 31287, 31288, 31290-31294, and 61548" added, for clarification of CPT code 61795 "Note" added to See "Policy" section for specific coverage of Stereotactic Radiosurgery
3/14/2006: Coding updated. HCPCS 2005 revisions added to policy
7/20/2006: Policy reviewed, prior authorization removed
8/18/2006: Policy and description rewritten and clarified; investigational status of extracranial sites added
9/5/2006: Code reference section updated. CPT code 61795 deleted. ICD9 procedure codes 92.31, 92.32, 92.33, 92.39 deleted. ICD9 diagnosis codes 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 197.0, 231.2, 237.0, 237.1, 253.0, 255.0, 332.0, 333.1, HCPC S8030 deleted
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
9/18/2007: Policy reviewed, no changes
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
10/21/2009: Coding Section Updated to add CPT4 code 61795 back to Covered Codes Table, and to add HCPCS code S8030 back to the Covered Codes Table
10/29/2009: Policy Title revised to include, "and Stereotactic Body Radiation therapy (SBRT), Description Section updated with energy sources and characteristics for gamma-ray radiosurgery and linear-accelerator radiosurgery, removed Helium ion radiosurgery, Proton-beam radiosurgery, and Neutron-beam radiosurgery, removed description information for the three radiation-delivery devices, added applications for SRS, added link to Proton or Helium Ion Radiation Therapy medical policy. Policy Statement Section revised to include SBRT is now considered medically necessary in specific cases of both non-small cell lung cancer and spinal or vertebral body tumors. Coding Section revised to include coding information guidelines for describing the procedure and delivery reporting, added verbiage to CPT4 code 20660 "(this code may have been used previous to 1-1-2009 to code the attachment of the head frame), added verbiage to CPT 4 codes 61795- 61799 "(Use for clinical treatment management by the neurosurgeon)", moved CPT4 codes 63620- 63621 from Non-Covered Codes Table to the Covered Codes Table and added verbiage "(Use specifically for stereotactic radiation treatment delivery)", added verbiage to CPT4 code 77299 "(Use for clinical treatment planning)", added verbiage to CPT4 codes 77371- 77372 "(Use specifically for stereotactic radiation treatment delivery)", added CPT 4 codes 77373 and 77435 to Covered Codes Table with verbiage "(Use specifically for stereotactic body radiation treatment delivery)", added verbiage to CPT4 code 77399 "(Use for medical radiation physics)", added CPT4 codes 77402- 77416 to Covered Codes Table with verbiage "(Use for treatment delivery)", added verbiage to CPT4 code 77432 "(Use for concurrent treatment management performed by the radiation oncologist)", added ICD9 procedure codes 92.31- 92.39 to Covered Codes Table, added verbiage to ICD9 procedure code 93.59 "(May use for stereotactic head frame application)", added ICD9 diagnosis codes 162.2- 162.9 to Covered Codes Table, added ICD9 diagnosis code 170.2 to Covered Codes Table, corrected description of ICD9 diagnosis code 198.3, removed deleted HCPCS code G0243 from Covered Codes Table, removed deleted CPT4 code 61793 from Covered Codes Table, removed the Non-Covered Codes Table, Removed CPT4 Codes 77520, 77522, 77523, 77525 from Covered Codes Table, HCPCS code S8030 removed from Covered Codes Table
04/28/2010: Policy description and statement unchanged. FEP verbiage added to the Policy Exceptions section.
12/30/2010: Policy statement regarding non-small cell lung cancer updated to state "T1 or T2a non-small cell lung cancer (not larger than 5 cm)" is considered medically necessary.
02/28/2011: Added new CPT codes 61781-61783 to the Code Reference section.
07/19/2012: Policy statement revised to indicate that SRS may be considered medically necessary for craniopharyngiomas and glomus tumors, and SBRT may be considered medically necessary for spinal or vertebral metastases that are radioresistant (e.g., renal cell carcinoma, melanoma and sarcoma). Deleted the following statement: Stereotactic body radiation therapy (SBRT) is considered investigational in the treatment of extracranial sites, except for cases of spinal tumors after prior radiation therapy and stage 1 non-small cell lung cancer as noted above. Added policy statement to state that when stereotactic radiosurgery or stereotactic body radiation therapy are performed using fractionation for the medically necessary indications described, it is considered medically necessary. Policy statement added to state that SBRT is considered investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate. Removed deleted CPT code 61795 from the Code Reference section, and added the following ICD-9 codes as covered: 194.6, 198.3, 237.0, 237.3.
12/13/2013: Policy statement updated to state that SRS is considered investigational for uveal melanoma.
12/31/2014: Code Reference section updated to revise the description of the following CPT codes: 77402, 77407, and 77412. Added the following new 2015 HCPCS codes: G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014.
08/27/2015: Code Reference section updated to add ICD-10 codes.
06/07/2016: Policy number A.6.01.10 added. Policy Guidelines updated to add medically necessary and investigative definitions.
07/28/2017: Removed invalid procedure code 2W30X8Z and added 2W30XYZ. Removed deleted CPT codes 77403, 77404, 77406, 77408, 77409, 77411, 77413, 77414, 77416 and HCPCS codes G0173 and G0251.
12/11/2017: Policy description extensively re-written. Policy section and policy guidelines updated to change "radiation therapy" to "radiotherapy." Investigational statement regarding stereotactic radiosurgery for applications updated to include treatment of tremors. Policy statement updated to state that stereotactic body radiotherapy is investigational for primary and metastatic tumors of the liver, pancreas, kidney, adrenal glands and prostate, except as outlined in the policy statements.
06/01/2019: Policy description extensively revised. First two medically necessary policy statements updated to add additional indications. Uveal melanoma changed from investigational to medically necessary. Investigational statement revised to state that stereotactic body radiotherapy is investigational for prostate cancer, pancreatic adenocarcinoma and other conditions, except as outlined in the policy statements above. Code Reference section updated to add CPT code 32701 and ICD-10 diagnosis codes C22.0, C22.9, C64.1 – C64.9, C69.30 – C69.32, C69.40 – C69.42, C69.80 – C69.82, C72.0, C78.00 – C78.02, C78.7, C7B.02, C79.51, C79.70 – C79.72, G40.001 – G40.019, G40.101 – G40.119, and G40.201 – G40.219.
01/21/2020: Policy reviewed. Investigational statement revised to add "other applications" to statement.
02/03/2021: Policy description updated. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."
08/30/2021: Policy reviewed; no changes.
11/09/2022: Policy reviewed. Policy statements and Policy Guidelines updated to change "patients" to "individuals." Code Reference section updated to remove CPT code 61783.
08/09/2023: Policy description updated regarding cancer risk by racial/ethnic groups. Medically necessary policy statement revised with minor wording change for consistency among policy statements. Policy Guidelines updated regarding radiation source.
12/21/2023: Code Reference section updated to add new 2024 HCPCS code C9795, effective 01/01/2024.
12/20/2024: Code Reference section updated to add new HCPCS code G0563 effective 01/01/2025.
03/19/2025: Policy reviewed. Policy statement revised to add small cell lung cancer as an investigational indication for stereotactic body radiotherapy.
01/15/2026: Code Reference section updated to remove ICD-9 diagnosis codes and revise the code descriptions for CPT codes 77402, 77407, and 77412. Effective 01/01/2026.
Blue Cross Blue Shield Association policies # 6.01.10 and # 8.01.10
Hayes Medical Technology Directory
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Coding for SRS typically consists of a series of CPT codes describing the individual steps required:
Medical radiation physics
Clinical treatment planning
Attachment of stereotactic head frame
Treatment delivery
Clinical treatment management
The codes used for treatment delivery will depend on the energy source used.
The SRS surgical CPT codes are reported per lesion not to exceed 5 lesions in the cranial SRS coding or 3 lesions in the spinal SRS coding per course of treatment.
Covered Codes
Code Number | Description |
|---|---|
CPT-4 | |
20660 | Application of cranial tongs, caliper, or stereotactic frame, including removal |
32701 | Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or particle beam), entire course of treatment |
61781 | Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure) |
61782 | Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure) |
61796 | (Use for clinical treatment management by the neurosurgeon) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion |
61797 | (Use for clinical treatment management by the neurosurgeon) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion , simple (List separately in addition to code for primary procedure) |
61798 | (Use for clinical treatment management by the neurosurgeon) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion |
61799 | (Use for clinical treatment management by the neurosurgeon) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure) |
61800 | (May use for stereotactic head frame application) Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) |
63620 | (Use for clinical treatment management by the neurosurgeon) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion |
63621 | (Use for clinical treatment management by the neurosurgeon) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure) |
77299 | (Use for clinical treatment planning) Unlisted procedure, therapeutic radiology clinical treatment planning |
77371 | (Use specifically for stereotactic radiation treatment delivery) Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based |
77372 | (Use specifically for stereotactic radiation treatment delivery) Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based |
77373 | (Use specifically for stereotactic body radiation treatment delivery) Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions |
77399 | (Use for medical radiation physics) Unlisted procedure, medical radiation physics, dosimetry, and treatment devices, and special services |
77435 | (Use specifically for stereotactic body radiation treatment delivery) Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions |
77402 | (Use for treatment delivery) Radiation treatment delivery; Level 1 (eg, single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed (Revised 01/01/2026) |
77407 | (Use for treatment delivery) Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed (Revised 01/01/2026) |
77412 | (Use for treatment delivery) Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (eg, 2D, 3D, or IMRT) or a single-isocenter photon therapy (eg, 3D or IMRT) with active motion management, or total skin electrons, or mixed-electron/photon field(s), including imaging guidance, when performed (Revised 01/01/2026) |
77432 | (Use for concurrent treatment management performed by the radiation oncologist) Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) |
HCPCS | |
C9795 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions |
G0339 | Image guided robotic linear accelerator base 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 |
G0563 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance and real-time positron emissions-based delivery adjustments to 1 or more lesions, entire course not to exceed 5 fractions |
G6003 | Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5mev |
G6004 | Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10mev (Deleted 12/31/2025) |
G6005 | Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19mev (Deleted 12/31/2025) |
G6006 | Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20mev or greater (Deleted 12/31/2025) |
G6007 | Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5mev (Deleted 12/31/2025) |
G6008 | Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10mev (Deleted 12/31/2025) |
G6009 | Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19mev (Deleted 12/31/2025) |
G6010 | Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 mev or greater (Deleted 12/31/2025) |
G6011 | Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5mev (Deleted 12/31/2025) |
G6012 | Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10mev (Deleted 12/31/2025) |
G6013 | Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19mev (Deleted 12/31/2025) |
G6014 | Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20mev or greater (Deleted 12/31/2025) |
ICD-10 Procedure | |
D020DZZ | Stereotactic radiosurgery of brain |
D021DZZ | Stereotactic radiosurgery of brain stem |
DG20DZZ | Stereotactic other photon radiosurgery of pituitary gland |
D920DZZ | Stereotactic other photon radiosurgery of ear |
DB21DZZ, DB22DZZ | Stereotactic other photon radiosurgery of bronchus and lung |
D026DZZ | Stereotactic other photon radiosurgery of spinal cord |
DW21DZZ | Stereotactic other photon radiosurgery of head and neck |
D020JZZ, D021JZZ | Stereotactic gamma beam radiosurgery of brain and brain stem |
D920JZZ | Stereotactic gamma beam radiosurgery of ear |
DB21JZZ, DB22JZZ | Stereotactic gamma beam radiosurgery of bronchus and lung |
DG20JZZ | Stereotactic gamma beam radiosurgery of pituitary gland |
DW21JZZ | Stereotactic gamma beam radiosurgery of head and neck |
D020HZZ, D021HZZ | Stereotactic particulate radiosurgery of brain and brain stem |
D026HZZ | Stereotactic particulate radiosurgery of spinal cord |
D920HZZ | Stereotactic particulate radiosurgery of ear |
DB21HZZ, DB22HZZ | Stereotactic particulate radiosurgery of bronchus and lung |
DG20HZZ | Stereotactic particulate radiosurgery of pituitary gland |
D020DZZ, D021DZZ, D026DZZ, D920DZZ, DB21DZZ, DB22DZZ, DG20DZZ, DW21DZZ | (See descriptions above) |
2W30XYZ | Immobilization of head using other device |
ICD-10 Diagnosis | |
C22.0 | Liver cell carcinoma |
C22.9 | Malignant neoplasm of liver, not specified as primary or secondary |
C34.00, C34.01, C34.02 | Malignant neoplasm of bronchus |
C34.10, C34.11, C34.12 | Malignant neoplasm of upper lobe |
C34.2 | Malignant neoplasm of middle lobe |
C34.30, C34.31, C34.32 | Malignant neoplasm of lower lobe |
C34.80, C34.81, C34.82 | Malignant neoplasm of overlapping sites or bronchus and lung |
C34.90, C34.91, C34.92 | Malignant neoplasm of unspecified par of bronchus and lung |
C41.2 | Malignant neoplasm of vertebral column |
C64.1 - C64.9 | Malignant neoplasm of kidney, except renal pelvis |
C69.30 - C69.32 | Malignant neoplasm of choroid |
C69.40 - C69.42 | Malignant neoplasms of ciliary body |
C69.80 - C69.82 | Malignant neoplasm of overlapping sites of eye and adnexa |
C71.0 | Malignant neoplasm of cerebrum, except lobes and ventricles |
C71.1 | Malignant neoplasm of frontal lobe |
C71.2 | Malignant neoplasm of temporal lobe |
C71.3 | Malignant neoplasm of parietal lobe |
C71.4 | Malignant neoplasm of occipital lobe |
C71.5 | Malignant neoplasm of cerebral ventricle |
C71.6 | Malignant neoplasm of cerebellum |
C71.7 | Malignant neoplasm of brain stem |
C71.8 | Malignant neoplasm of overlapping sites of brain |
C71.9 | Malignant neoplasm of brain, unspecified |
C72.0 | Malignant neoplasm of spinal cord |
C75.5 | Malignant neoplasm of aortic body and other paraganglia (includes glomus jugulare tumors) |
C78.00 - C78.02 | Secondary malignant neoplasm of lung |
C78.7 | Secondary malignant neoplasm of liver and intrahepatic bile duct |
C7B.02 | Secondary carcinoid tumors of liver |
C79.31 | Secondary malignant neoplasm of brain |
C79.51 | Secondary malignant neoplasm of bone |
C79.70 - C79.72 | Secondary malignant neoplasm of adrenal gland |
D32.0 | Benign neoplasm of cerebral meninges |
D32.9 | Benign neoplasm of meninges, unspecified |
D33.3 | Benign neoplasm of cranial nerves (acoustic neuroma) |
D35.2 | Benign neoplasm of pituitary gland (pituitary adenoma) |
D35.3 | Benign neoplasm of craniopharyngeal duct |
D44.4 | Neoplasm of uncertain behavior of craniopharyngeal duct |
D44.7 | Neoplasm of uncertain behavior of aortic body and other paraganglia (includes glomus jugulare tumors) |
G40.001 - G40.019 | Localization-related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset |
G40.101 - G40.119 | Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures |
G40.201 - G40.219 | Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures |
G50.0 | Trigeminal neuralgia |
Q28.2 | Arteriovenous malformation of cerebral vessels |
Q28.3 | Other malformations of cerebral vessels |
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