Radiation Therapy for Non-Cancerous Conditions - CAM 758

Description/Backgound
Radiation therapy may have appropriate use in several non-malignant conditions. The treatment goal in patients with non-malignant conditions is to achieve relief of the indicated condition with radiation therapy with minimal risk of radiation exposure to sensitive structures.

Policy 
INDICATIONS FOR RADIATION THERAPY 
2D or 3D Conformal (3D CRT) is considered MEDICALLY NECESSARY for several non-malignant conditions, including but not limited to (McKeown, 2015):

  • Prevention of keloid scars as an adjunctive therapy following excisional surgery
  • Heterotopic ossification
  • Pterygium in cases that cannot be medically managed
  • Villonodular synovitis 

Stereotactic Radiation Therapy (SRS, SBRT) is considered MEDICALLY NECESSARY when used in the treatment of non-malignant cranial lesions including the following (ASTRO, 2014):

  • Arteriovenous malformation (AVM) of the brain or spine.
  • Trigeminal neuralgia that has not responded to other, more conservative, treatments.
  • Non cancerous brain tumors such as acoustic neuroma, benign schwannomas, meningioma, hemangioma, pituitary adenoma, craniopharyngioma, neoplasm of the pineal gland, and chordomas 

 

TREATMENT OPTIONS REQUIRING PHYSICIAN REVIEW: 
Treatment for other non-malignant conditions utilizing proton beam, stereotactic radiation therapy (SBRT), or intensity modulated radiation therapy (IMRT) modalities should be referred to physician review.

References 

  1. American Society for Radiation Oncology (ASTRO). Model policies. Stereotactic Radiosurgery (SRS). 2014. 
  2. Aqqarwal A, Fersht N, Brada M. Radiotherapy for craniopharyngioma. Pituitary. March 2013; 16(1):26-33. doi: 10.1007/s11102-012-0429-1.  
  3. Bentzen SM, Constine LS, Deasy JO, et al. Quantitative analyses of normal tissue effects in the clinic QUANTEC: An introduction to the scientific issues.  Introductory paper. Int J Radiat Oncol Biol Phys. 2010; 76(3):S3-S9. 
  4. Casentini L, Fornezza U, Perini Z, et al. Multisession stereotactic radiosurgery for large vestibular schwannomas.  J Neurosurg. 2015; 16:1-7. 
  5. Combs SE, Engelhand C, Kopp C, et al. Long-term outcome after highly advanced single-dose or fractionated radiotherapy in patients with vestibular schwannomas - Pooled results from 3 large German centers. Radiother Oncol. March 2015; 114(3):378-383. doi: 10.1016/j.radonc.2015.01.011. 
  6. Ding D, Yen CP, Starke RM, et al. Unyielding progress: Recent advances in the treatment of central nervous system neoplasms with radiosurgeryand radiation therapy.  J Neurooncol. 2014; 119(3):513-529. doi: 10.1007/s11060-014-1501-7. 
  7. Flickinger JC.  A radiobiological analysis of multicenter data for postoperative keloid radiotherapy.  Int J Radiat Oncol Biol Phys. March 15, 2011; 79(4):1164-1170. doi: 10.1016/j.ijrobp.2009.12.019.  
  8. Gross CE, Frank RM, Hsu AR, et al. External Beam Radiation Therapy for Orthopaedic Pathology. J Am Acad Orthop Surg. April 2015; 23(4):243-252. 
  9. Hasan S, Young M, Albert T, et al. The role of adjuvant radiotherapy after gross total resection of atypical meningiomas. [Published online ahead of print December 19, 2014]. World Neurosurg.May 2015; 83(5):808-815. doi: 10.1016/j.wneu.2014.12.037.
  10. Jackson A, Marks LB, Bentzen SM, et al. The lessons of QUANTEC:  Recommendations for reporting and gathering data on dose-volume dependencies of treatment outcome. Int J Radiat Oncol Biol Phys. 2010; 76(3):S155-S160.
  11. Kondziolka D, Perez B, Flickinger JC, et al.  Gamma knife radiosurgery for trigeminal neuralgia: Results and expectations. Arch Neurol. 1998; 55(12):1524-1529.
  12. Luis AM. Radiotherapy for non-malignant diseases. Reports of Practical Oncology and Radiotherapy. June 2013. https://www.researchgate.net/profile/Angel_Montero/publication/257606206_Radiotherapy_for_non-malignant_diseases/links/59f8b3eb458515547c26a20f/Radiotherapy-for-non-malignant-diseases.pdf?origin=publication_detail. Accessed May 2, 2018.
  13. Maesawa S, Salame C, Flickinger JC, et al. Clinical outcomes after stereotactic radiosurgery for idiopathic trigeminal neuralgia. J Neurosurg. 2001; 94(1):14-20.
  14. Maniakas A, Saliba I. Microsurgery versus stereotactic radiation for small vestibular schwannomas: A meta-analysis of patients with more than 5 years' follow-up. Otol Neurotol. 2012; 33(9):1611-1620. 
  15. McKeown SR, Hatfield P, Prestwich RJ, et al.  Radiotherapy for benign disease: Assessing the risk of radiation-induced cancer following exposure to intermediate dose radiation. Br J Radiol. 2015; 88(1056):20150405. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4984935/. Accessed May 2, 2018. 
  16. Pashtan I, Oh KS, Loeffler JS. Radiation therapy in the management of pituitary adenomas. Handb Clin Neurol. 2014; 124:317-24. doi: 10.1016/B978-0-444-59602-4.00021-6. 
  17. Popovic M, Aqarwal A, Zhang L, et al. Radiotherapy for the prophylaxis of heterotopic ossification: A systematic review and meta-analysis of published data.  Radiother Oncol. October 2014; 113(1):10-17. doi: 10.1016/j.radonc.2014.08.025. 
  18. Portnow LH, Scott M, Morris CG, et al. Fractionated radiotherapy in the management of benign vascular tumors. Am J Clin Oncol. December 2012; 35(6):557-561. doi: 10.1097/COC.0b013e31821f847f. 
  19. Seregard S, Pelayes DE, Singh AD. Radiation therapy: Uveal tumors. Dev Ophthalmol. 2013; 52:36-57. doi: 10.1159/000351055. 
  20. Seegenschmiedt MH, Micke O, Muecke R, et al. Radiotherapy for non-malignant disorders: State of the art and update of the evidence-based practice guidelines. Br J Radiol. 2015; 88(1051):20150080. http://doi.org/10.1259/bjr.20150080. Accessed May 15, 2017. 
  21. Sonier M, Gete E, Herbert C, et al. Intensity-modulated stereotactic radiosurgery for arteriovenous malformations: Guidance for treatment planning. Radiat Oncol. March 10, 2014; 9:73. doi: 10.1186/1748-717X-9-73.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2020 Forward     

12/01/2021 

Annual review, no change to policy intent. 

01/01/2021

New Policy

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