Stereotactic Radiosurgery and Stereotactic Body Radiotherapy

When Policy Topic is covered Stereotactic radiosurgery using a gamma or LINAC unit may be considered medically necessary for the following indications:  arteriovenous malformations;  acoustic neuromas;  pituitary adenomas;  non-resectable, residual, or recurrent meningiomas;  craniopharyngiomas;  glomus jugulare tumors;  solitary or multiple brain metastases in patients having good performance status and no active systemic disease (defined as extracranial disease that is stable or in remission);  primary malignancies of the CNS, including but not limited to high-grade gliomas (initial treatment or treatment of recurrence);  trigeminal neuralgia refractory to medical management.