Aetna · Clinical coverage policy

Aetna Stereotactic Radiosurgery coverage criteria

Aetna CPB 0083 covers stereotactic radiosurgery (SRS/SBRT) as medically necessary in certain circumstances but does not list the specific criteria itself — it defers all medical-necessity determinations to the eviCore Healthcare Radiation Therapy Clinical Guidelines. ICD-10 tables indicate it is covered, when selection criteria are met, for conditions such as malignant neoplasms, benign/brain tumors, hemangioblastoma, AVMs, nonruptured cerebral aneurysm, trigeminal neuralgia, essential tremor, and Parkinson's/secondary parkinsonism, while epilepsy/seizures, cluster headache and trigeminal autonomic cephalgias, and breast microcalcification are listed as not covered.

Policy CPB 0083 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0083

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0083 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Stereotactic Radiosurgery (CPT 61796), and what gets it denied?

Path
Aetna CPB 0083 covers stereotactic radiosurgery (SRS/SBRT) as medically necessary in certain circumstances but does not list the specific criteria itself — it defers all medical-necessity determinations to the eviCore Healthcare Radiation Therapy Clinical Guidelines. ICD-10 tables indicate it is covered, when selection criteria are met, for conditions such as malignant neoplasms, benign/brain tumors, hemangioblastoma, AVMs, nonruptured cerebral aneurysm, trigeminal neuralgia, essential tremor, and Parkinson's/secondary parkinsonism, while epilepsy/seizures, cluster headache and trigeminal autonomic cephalgias, and breast microcalcification are listed as not covered. Coverage criteria include: Aetna considers stereotactic radiosurgery medically necessary in certain circumstances. For medical necessity criteria, see eviCore Healthcare Radiation Therapy Clinical Guidelines. (The Policy section defers all specific medical-necessity criteria to the eviCore Healthcare Radiation Therapy Clinical Guidelines and does NOT enumerate specific covered diagnoses inline.); Note: eviCore guidelines undergo formal annual review; however, eviCore reserves the right to change and update guidelines without prior notice.; Covered if selection criteria are met (per eviCore guidelines) — Malignant neoplasms (ICD-10 C00.0–C96.9); Covered if selection criteria are met (per eviCore guidelines) — Hemangioma [hemangioblastoma] (ICD-10 D18.00–D18.09); Covered if selection criteria are met (per eviCore guidelines) — Benign neoplasm of brain (ICD-10 D33.0–D33.2); Covered if selection criteria are met (per eviCore guidelines) — Parkinson's disease (ICD-10 G20.A1–G20.C); Covered if selection criteria are met (per eviCore guidelines) — Secondary parkinsonism (ICD-10 G21.0–G21.9); Covered if selection criteria are met (per eviCore guidelines) — Essential tremor (ICD-10 G25.0); Covered if selection criteria are met (per eviCore guidelines) — Trigeminal neuralgia (ICD-10 G50.0); Covered if selection criteria are met (per eviCore guidelines) — Cerebral aneurysm, nonruptured (ICD-10 I67.1); Covered if selection criteria are met (per eviCore guidelines) — Other congenital malformations of circulatory system [e.g., arteriovenous malformations] (ICD-10 Q28.2–Q28.3). Applies to 12 codes: 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: Not covered indication — Epilepsy and recurrent seizures (ICD-10 G40.001–G40.919); Not covered indication — Cluster headache and trigeminal autonomic cephalgias (ICD-10 G44.001–G44.099); Not covered indication — Post traumatic seizures (ICD-10 R56.1); Not covered indication — Unspecified convulsions [seizures NOS] (ICD-10 R56.9); Not covered indication — Mammographic microcalcification found on diagnostic imaging of breast (ICD-10 R92.0); The efficacy of SRS in the management of epilepsy appears not to have been established, other than in association with its use in treatment for AVMs or brain tumors (Alberta Heritage Foundation review, 2002).; The place of SRS in the treatment of Parkinson's disease does not appear to be established.; For advanced pancreatic carcinoma, SBRT was associated with poor outcome, unacceptable toxicity and questionable palliative effect and cannot be recommended for patients with advanced pancreatic carcinoma (Hoyer et al, 2005).; For cluster headache, the morbidity was found to be significant for the low rate of pain cessation, making this procedure less attractive (Donnet et al, 2005).; For cervical cancer, SBRT should not be considered a substitute for brachytherapy (Expert Panel on Radiation Oncology). Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0083 — Stereotactic Radiosurgery

Coverage criteria

  • Aetna considers stereotactic radiosurgery medically necessary in certain circumstances. For medical necessity criteria, see eviCore Healthcare Radiation Therapy Clinical Guidelines. (The Policy section defers all specific medical-necessity criteria to the eviCore Healthcare Radiation Therapy Clinical Guidelines and does NOT enumerate specific covered diagnoses inline.)
  • Note: eviCore guidelines undergo formal annual review; however, eviCore reserves the right to change and update guidelines without prior notice.
  • Covered if selection criteria are met (per eviCore guidelines) — Malignant neoplasms (ICD-10 C00.0–C96.9)
  • Covered if selection criteria are met (per eviCore guidelines) — Hemangioma [hemangioblastoma] (ICD-10 D18.00–D18.09)
  • Covered if selection criteria are met (per eviCore guidelines) — Benign neoplasm of brain (ICD-10 D33.0–D33.2)
  • Covered if selection criteria are met (per eviCore guidelines) — Parkinson's disease (ICD-10 G20.A1–G20.C)
  • Covered if selection criteria are met (per eviCore guidelines) — Secondary parkinsonism (ICD-10 G21.0–G21.9)
  • Covered if selection criteria are met (per eviCore guidelines) — Essential tremor (ICD-10 G25.0)
  • Covered if selection criteria are met (per eviCore guidelines) — Trigeminal neuralgia (ICD-10 G50.0)
  • Covered if selection criteria are met (per eviCore guidelines) — Cerebral aneurysm, nonruptured (ICD-10 I67.1)
  • Covered if selection criteria are met (per eviCore guidelines) — Other congenital malformations of circulatory system [e.g., arteriovenous malformations] (ICD-10 Q28.2–Q28.3)

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Stereotactic Radiosurgery (CPT 61796), and what gets it denied?
Aetna CPB 0083 covers stereotactic radiosurgery (SRS/SBRT) as medically necessary in certain circumstances but does not list the specific criteria itself — it defers all medical-necessity determinations to the eviCore Healthcare Radiation Therapy Clinical Guidelines. ICD-10 tables indicate it is covered, when selection criteria are met, for conditions such as malignant neoplasms, benign/brain tumors, hemangioblastoma, AVMs, nonruptured cerebral aneurysm, trigeminal neuralgia, essential tremor, and Parkinson's/secondary parkinsonism, while epilepsy/seizures, cluster headache and trigeminal autonomic cephalgias, and breast microcalcification are listed as not covered. Coverage criteria include: Aetna considers stereotactic radiosurgery medically necessary in certain circumstances. For medical necessity criteria, see eviCore Healthcare Radiation Therapy Clinical Guidelines. (The Policy section defers all specific medical-necessity criteria to the eviCore Healthcare Radiation Therapy Clinical Guidelines and does NOT enumerate specific covered diagnoses inline.); Note: eviCore guidelines undergo formal annual review; however, eviCore reserves the right to change and update guidelines without prior notice.; Covered if selection criteria are met (per eviCore guidelines) — Malignant neoplasms (ICD-10 C00.0–C96.9); Covered if selection criteria are met (per eviCore guidelines) — Hemangioma [hemangioblastoma] (ICD-10 D18.00–D18.09); Covered if selection criteria are met (per eviCore guidelines) — Benign neoplasm of brain (ICD-10 D33.0–D33.2); Covered if selection criteria are met (per eviCore guidelines) — Parkinson's disease (ICD-10 G20.A1–G20.C); Covered if selection criteria are met (per eviCore guidelines) — Secondary parkinsonism (ICD-10 G21.0–G21.9); Covered if selection criteria are met (per eviCore guidelines) — Essential tremor (ICD-10 G25.0); Covered if selection criteria are met (per eviCore guidelines) — Trigeminal neuralgia (ICD-10 G50.0); Covered if selection criteria are met (per eviCore guidelines) — Cerebral aneurysm, nonruptured (ICD-10 I67.1); Covered if selection criteria are met (per eviCore guidelines) — Other congenital malformations of circulatory system [e.g., arteriovenous malformations] (ICD-10 Q28.2–Q28.3). Applies to 12 codes: 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Not covered indication — Epilepsy and recurrent seizures (ICD-10 G40.001–G40.919); Not covered indication — Cluster headache and trigeminal autonomic cephalgias (ICD-10 G44.001–G44.099); Not covered indication — Post traumatic seizures (ICD-10 R56.1); Not covered indication — Unspecified convulsions [seizures NOS] (ICD-10 R56.9); Not covered indication — Mammographic microcalcification found on diagnostic imaging of breast (ICD-10 R92.0); The efficacy of SRS in the management of epilepsy appears not to have been established, other than in association with its use in treatment for AVMs or brain tumors (Alberta Heritage Foundation review, 2002).; The place of SRS in the treatment of Parkinson's disease does not appear to be established.; For advanced pancreatic carcinoma, SBRT was associated with poor outcome, unacceptable toxicity and questionable palliative effect and cannot be recommended for patients with advanced pancreatic carcinoma (Hoyer et al, 2005).; For cluster headache, the morbidity was found to be significant for the low rate of pain cessation, making this procedure less attractive (Donnet et al, 2005).; For cervical cancer, SBRT should not be considered a substitute for brachytherapy (Expert Panel on Radiation Oncology). Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Stereotactic Radiosurgery?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Stereotactic Radiosurgery?
Policy exclusions and limitations: Not covered indication — Epilepsy and recurrent seizures (ICD-10 G40.001–G40.919); Not covered indication — Cluster headache and trigeminal autonomic cephalgias (ICD-10 G44.001–G44.099); Not covered indication — Post traumatic seizures (ICD-10 R56.1); Not covered indication — Unspecified convulsions [seizures NOS] (ICD-10 R56.9); Not covered indication — Mammographic microcalcification found on diagnostic imaging of breast (ICD-10 R92.0); The efficacy of SRS in the management of epilepsy appears not to have been established, other than in association with its use in treatment for AVMs or brain tumors (Alberta Heritage Foundation review, 2002).; The place of SRS in the treatment of Parkinson's disease does not appear to be established.; For advanced pancreatic carcinoma, SBRT was associated with poor outcome, unacceptable toxicity and questionable palliative effect and cannot be recommended for patients with advanced pancreatic carcinoma (Hoyer et al, 2005).; For cluster headache, the morbidity was found to be significant for the low rate of pain cessation, making this procedure less attractive (Donnet et al, 2005).; For cervical cancer, SBRT should not be considered a substitute for brachytherapy (Expert Panel on Radiation Oncology). Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0083 — Stereotactic Radiosurgery

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0083 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.