HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
S-133-036
Topic:
Endovascular/Endoluminal Stent Grafts
Section:
Surgery
Effective Date:
March 11, 2019
Issued Date:
March 11, 2019
Last Revision Date:
February 2019
Annual Review:
February 2019
 
 

Endovascular/endoluminal grafts are minimally invasive alternatives to open surgical repair for treatment of traumatic aortic injury, thoracic aortic aneurysms (TAA), abdominal aortic aneurysms (AAAs), as well as iliac artery aneurysms. Open surgical repair has high morbidity and mortality, and endovascular/endoluminal grafts have the potential to reduce the operative risk associated with these repairs.

Policy Position

Thoracic Aortic Aneurysm

The use of FDA approved endovascular/endoluminal stent-graft devices may be considered medically necessary for the treatment of:

  • Aneurysms 23-37 mm of inner aortic diameter; or
  • Descending thoracic aortic aneurysms without dissection; or
  • Isolated lesions of the thoracic aorta (e.g. aneurysms, rupture, tears, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, traumatic disruption; or
  • Acute, complicated (organ or limb ischemia or rupture) Type B thoracic aortic dissection.

Endovascular/endoluminal stent grafts are considered experimental/investigational for the treatment of thoracic aortic arch aneurysms or Type A aortic dissections and are therefore non-covered.

33880

33881

33883

33884

33886

33889

33891

37799

75956

75957

75958

75959

 

 




Abdominal Aortic Aneurysm

The use of FDA approved endovascular/endoluminal stent-graft devices may be considered medically necessary as treatment of AAAs for ANY of the following indications:

  • Aneurysms measuring 5.0 centimeters or greater; or
  • Aneurysms measuring 4.5 to 5.0 centimeters that are rapidly expanding or are symptomatic; or
  • A ruptured AAA when BOTH of the following criteria is met:
    • The patient must be sufficiently stable to undergo detailed CT examination for anatomic measurements; and
    • The aneurysm should be anatomically appropriate for endovascular repair.

Specialized personnel should be available to assist with this procedure.

To monitor for leaking of the graft after implantation, individuals will typically undergo routine imaging with either computed tomography or ultrasonography every six (6) to 12 months, or more frequently if perivascular leaks or aneurysm enlargement is detected.

Endovascular stent grafting reported for any other indications is considered not medically necessary.

Placement and radiological guidance of endovascular stent-grafts are specific, more complex procedures as they involve the visceral vessels (superior mesenteric, celiac, or renal) and utilize a fenestrated prosthesis. These procedures are still being performed in clinical trial settings with no long-term outcomes available and therefore, are considered experimental/investigational, and are non-covered.

34701

34702

34703

34705

34706

34707

34708

34709

34710

34711

34712

34713

34714

34715

34716

34808

34813

34830

34831

34841

34842

34843

34844

34845

34846

34847

34848

 




Iliac Artery Aneurysm

The use of FDA approved endovascular/endoluminal stent-graft devices for iliac artery aneurysms may be considered medically necessary for the treatment of iliac aneurysms equal to or greater than 30mm in diameter.


Endovscular/endoluminal stent-graft devices for any other indication than listed above is considered not medically necessary.

34703

34704

34705

34706

34707

34709

34710

34711

34712

34713

34714

34808

 

 




Associated radiological services for the above procedures are considered medically necessary.

Advanced imaging for any other indication is considered not medically necessary.

 

34701

34702

34703

34705

34706

34707

34708

34709

34710

34711

75959

76706

 

 




Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation and instrument calibration, and collection of pressure data is considered experimental/investigational, and therefore non-covered. This procedure is still being performed in clinical trial settings.

Non-invasive physiologic study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair, complete study including recording, analysis of pressure and waveform tracings, interpretation and report is considered experimental/investigational, and therefore non-covered. This procedure is still being performed in clinical trial settings.

37799

 

 

 

 

 

 




Related Policies

Refer to Medical Policy X-134 Abdomen: Abdominal Aortic Aneurysm (AAA), Iliac Artery Aneurysm (IAA), and Visceral Artery Aneurysms Follow-Up of Known Aneurysms and Pre-Op Evaluation for additional information.

Refer to Medical policy X-135 Abdomen: Abdomen: Abdominal Aortic Aneurysm (AAA) and Iliac Artery Aneurysm (IAA)-Post Endovascular or Open Aortic Repair for additional information.


Covered Diagnosis Codes for Procedure Codes: 34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709, 34710, 34711, 34712, 34713, 34714, 34715, 34716, 34808, 34813, 34830, 34831

I71.2

I71.3

I71.4

I71.5

I71.6

I71.02

I71.03

I72.3

Q25.43

 

 

 

 

 

 

Covered Diagnosis Codes for Procedure Codes: 33880, 33881, 33883, 33884, 33886, 33889, 33891, 75956, 75957, 75958 and 75959

I71.1

I71.2

I71.5

I71.6

I71.01

I71.03

Q25.43

S25.00XA

S25.00XD

S25.00XS

S25.01XA

S25.01XD

S25.01XS

S25.02XA

S25.00XD

S25.00XS

S25.09XA

S25.09XD

S25.09XS

 

 

 

 

 

 

 

 

 



Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Endovascular/Endoluminal Stent Grafts is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

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