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.

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.

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.

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.

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

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

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.