Clinical UM Guideline
Subject: Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
Guideline #: CG-SURG-49 Publish Date: 12/16/2020
Status: Reviewed Last Review Date: 08/13/2020
Description

This document addresses the use of peripheral vascular angioplasty, with and without stenting, and with or without atherectomy, for the treatment of occlusive peripheral arterial disease (PAD) of the lower extremities.

Note: Procedures to address venous peripheral vascular disease are NOT addressed in this document.

Note: Please see the following document for additional information:

Clinical Indications

Medically Necessary:

A.  Treatment of Claudication

For individuals with claudication due to lower extremity occlusive arterial disease, the use of either percutaneous or open exposure angioplasty is considered medically necessary for individuals who meet ALL of the following criteria:

  1. Presence of severe disability (inability to perform usual work or life-style activities) due to intermittent claudication; and
  2. There has been an inadequate response to at least 6 months of conservative treatment including lifestyle initiatives for known risks (for example, smoking cessation and dietary changes), including supervised exercise training, and pharmacological therapy (for example, anti-platelet, cilostazol) unless contraindicated; and
  3. The targeted lesion has one of the following anatomic characteristics:
    1. Common iliac artery: unilateral or bilateral lesions of any length; or
    2. External iliac: unilateral or bilateral lesions less than or equal to 3 cm in length; or
    3. Femoral or popliteal artery: a single stenosis less than or equal to 10 cm in length or a single occlusion less than or equal to 5 cm in length; and
  4. There is an absence of other conditions that would limit activity even if the claudication were improved (for example, angina or chronic pulmonary disease) with the endovascular intervention.

For individuals with claudication due to lower extremity occlusive arterial disease, the use of either percutaneous or open exposure primary stent placement is considered medically necessary, when the following criteria have been met:

  1. Criteria above for angioplasty have been met; and
  2. Stenosis or occlusion is present in the common iliac artery, external iliac artery; or
  3. Stenosis or occlusion of intermediate-length (5-15 cm) is present in the femoropopliteal artery.

For individuals with claudication due to aortoiliac occlusive disease (AIOD), the use of covered stent devices is considered medically necessary in the presence of severe calcification or aneurysmal changes where the risk of rupture may be increased after unprotected dilation.

B.  Salvage (Provisional) Therapy for Claudication

For individuals with claudication due to lower extremity occlusive arterial disease, the use of either percutaneous or open exposure stents or atherectomy devices as salvage (provisional) therapy for a suboptimal or failed result from balloon angioplasty is considered medically necessary when the residual stenosis or occlusion is present in either the femoral, popliteal, or tibial artery and ANY of the following criteria have been met:

  1. Residual diameter stenosis greater than 50%; or
  2. Persistent translesional pressure gradient; or
  3. Flow-limiting dissection is present.

C.  Critical Limb Ischemia (CLI)

For individuals with limb threatening CLI due to lower extremity occlusive arterial disease (ischemic rest pain and/or impending limb loss with skin ulceration, gangrene, infection) of the lower extremity, the use of endovascular procedures (angioplasty, stent placement, or atherectomy) is considered medically necessary as initial or salvage therapy for inflow (aorto-iliac) and outflow (infrainguinal) occlusive vascular disease.

Note: The optimal strategy for the management of an individual with CLI is determined on a case by case basis by the treating physician and influenced by the urgency of the limb threat, comorbidities, and the individual’s arterial anatomy. 

Not Medically Necessary:

The use of percutaneous or open exposure angioplasty, with or without stent placement, and with or without atherectomy for the treatment of individuals with claudication due to lower extremity occlusive arterial disease is considered not medically necessary when the criteria above have not been met, including its use as prophylactic therapy in an asymptomatic individual with lower extremity PAD, or for claudication due to isolated infrapopliteal artery disease.

The use of primary stent placement for the treatment of claudication caused by isolated lesions in the infrapopliteal or tibial arteries is considered not medically necessary.

The use of peripheral vascular angioplasty, with or without stenting, and with or without atherectomy, is considered not medically necessary for treatment of occlusive arterial disease of the deep femoral artery (profunda femoris).

The use of endovascular procedures (angioplasty, stent placement, or atherectomy) for the treatment of CLI due to lower extremity occlusive arterial disease is considered not medically necessary as initial or salvage therapy for inflow (aorto-iliac) and outflow (infrainguinal) occlusive vascular disease in the absence of clinical symptoms of limb threatening CLI or when the medically necessary criteria for treatment of claudication above are not met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT

 

37220

Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

37221

Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37222

Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty

37223

Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37224

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty

37225

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed

37226

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37227

Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

37228

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty

37229

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed

37230

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

37231

Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

37232

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty

37233

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

37234

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

37235

Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

0505T

Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion

0620T

Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed [Note: code effective 01/01/2021]

 

 

ICD-10 Procedure

 

047C041-047C4ZZ

Dilation of right common iliac artery [with or without drug-eluting or other intraluminal device and number of devices, or drug-coated balloon, by approach; includes codes 047C041, 047C04Z, 047C05Z, 047C06Z, 047C07Z, 047C0D1, 047C0DZ, 047C0EZ, 047C0FZ, 047C0GZ, 047C0Z1, 047C0ZZ, 047C341, 047C34Z, 047C35Z, 047C36Z, 047C37Z, 047C3D1, 047C3DZ, 047C3EZ, 047C3FZ, 047C3GZ, 047C3Z1, 047C3ZZ, 047C441, 047C44Z, 047C45Z, 047C46Z, 047C47Z, 047C4D1, 047C4DZ, 047C4EZ, 047C4FZ, 047C4GZ, 047C4Z1, 047C4ZZ]

047D041-047D4ZZ

Dilation of left common iliac artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047D041, 047D04Z, 047D05Z, 047D06Z, 047D07Z, 047D0D1, 047D0DZ, 047D0EZ, 047D0FZ, 047D0GZ, 047D0Z1, 047D0ZZ, 047D341, 047D34Z, 047D35Z, 047D36Z, 047D37Z, 047D3D1, 047D3DZ, 047D3EZ, 047D3FZ, 047D3GZ, 047D3Z1, 047D3ZZ, 047D441, 047D44Z, 047D45Z, 047D46Z, 047D47Z, 047D4D1, 047D4DZ, 047D4EZ, 047D4FZ, 047D4GZ, 047D4Z1, 047D4ZZ]

047E041-047E4ZZ

Dilation of right internal iliac artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047E041, 047E04Z, 047E05Z, 047E06Z, 047E07Z, 047E0D1, 047E0DZ, 047E0EZ, 047E0FZ, 047E0GZ, 047E0Z1, 047E0ZZ, 047E341, 047E34Z, 047E35Z, 047E36Z, 047E37Z, 047E3D1, 047E3DZ, 047E3EZ, 047E3FZ, 047E3GZ, 047E3Z1, 047E3ZZ, 047E441,  047E44Z, 047E45Z, 047E46Z, 047E47Z, 047E4D1, 047E4DZ, 047E4EZ, 047E4FZ, 047E4GZ, 047E4Z1, 047E4ZZ]

047F041-047F4ZZ

Dilation of left internal iliac artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047F041, 047F04Z, 047F05Z, 047F06Z, 047F07Z, 047F0D1, 047F0DZ, 047F0EZ, 047F0FZ, 047F0GZ, 047F0Z1, 047F0ZZ, 047F341, 047F34Z, 047F35Z, 047F36Z, 047F37Z, 047F3D1, 047F3DZ, 047F3EZ, 047F3FZ, 047F3GZ, 047F3Z1, , 047F3ZZ, 047F441, 047F44Z, 047F45Z, 047F46Z, 047F47Z, 047F4D1, 047F4DZ, 047F4EZ, 047F4FZ, 047F4GZ, 047F4Z1, 047F4ZZ]

047H041-047H4ZZ

Dilation of right external iliac artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047H041, 047H04Z, 047H05Z, 047H06Z, 047H07Z, 047H0D1, 047H0DZ, 047H0EZ, 047H0FZ, 047H0GZ, 047H0Z1, 047H0ZZ, 047H341, 047H34Z, 047H35Z, 047H36Z, 047H37Z, 047H3D1, 047H3DZ, 047H3EZ, 047H3FZ, 047H3GZ, 047H3Z1, 047H3ZZ, 047H441, 047H44Z, 047H45Z, 047H46Z, 047H47Z, 047H4D1, 047H4DZ, 047H4EZ, 047H4FZ, 047H4GZ, 047H4Z1, 047H4ZZ]

047J041-047J4ZZ

Dilation of left external iliac artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047J041, 047J04Z, 047J05Z, 047J06Z, 047J07Z, 047J0D1, 047J0DZ, 047J0EZ, 047J0FZ, 047J0GZ, 047J0Z1, 047J0ZZ, 047J341, 047J34Z, 047J35Z, 047J36Z, 047J37Z, 047J3D1, 047J3DZ, 047J3EZ, 047J3FZ, 047J3GZ, 047J3Z1, 047J3ZZ, 047J441, 047J44Z, 047J45Z, 047J46Z, 047J47Z, 047J4D1, 047J4DZ, 047J4EZ, 047J4FZ, 047J4GZ, 047J4Z1, 047J4ZZ]

047K041-047K4ZZ

Dilation of right femoral artery [with or without drug-eluting device, drug-coated balloon or other intraluminal device and number of devices, by approach; includes codes 047K041, 047K04Z, 047K05Z, 047K06Z, 047K07Z, 047K0D1, 047K0DZ, 047K0EZ, 047K0FZ, 047K0GZ, 047K0Z1, 047K0ZZ, 047K341, 047K34Z, , 047K35Z, 047K36Z, 047K37Z, 047K3D1, 047K3DZ, 047K3EZ, 047K3FZ, 047K3GZ, 047K3Z1, 047K3ZZ, 047K441, 047K44Z, 047K45Z, 047K46Z, 047K47Z, 047K4D1, 047K4DZ, 047K4EZ, 047K4FZ, 047K4GZ, 047K4Z1, 047K4ZZ]

047L041-047L4ZZ

Dilation of left femoral artery [with or without drug-eluting device, drug-coated balloon or other intraluminal device and number of devices, by approach; includes codes 047L041, 047L04Z, 047L05Z, 047L06Z, 047L07Z, 047L0D1, 047L0DZ, 047L0EZ, 047L0FZ, 047L0GZ, 047L0Z1, 047L0ZZ, 047L341, 047L34Z, 047L35Z, 047L36Z, 047L37Z, 047L3D1, 047L3DZ, 047L3EZ, 047L3FZ, 047L3GZ, 047L3Z1, 047L3ZZ, 047L441, 047L44Z, 047L45Z, 047L46Z, 047L47Z, 047L4D1, 047L4DZ, 047L4EZ, 047L4FZ, 047L4GZ, 047L4Z1, 047L4ZZ]

047M041-047M4ZZ

Dilation of right popliteal artery [with or without drug-eluting device, drug-coated balloon or other intraluminal device and number of devices, by approach; includes codes 047M041, 047M04Z, 047M05Z, 047M06Z, 047M07Z, 047M0D1, 047M0DZ, 047M0EZ, 047M0FZ, 047M0GZ, 047M0Z1, 047M0ZZ, 047M341, 047M34Z, 047M35Z, 047M36Z, 047M37Z, 047M3D1, 047M3DZ, 047M3EZ, 047M3FZ, 047M3GZ, 047M3Z1, 047M3ZZ, 047M441, 047M44Z, 047M45Z, 047M46Z, 047M47Z, 047M4D1, 047M4DZ, 047M4EZ, 047M4FZ, 047M4GZ, 047M4Z1, 047M4ZZ]

047N041-047N4ZZ

Dilation of left popliteal artery [with or without drug-eluting device, drug-coated balloon or other intraluminal device and number of devices, by approach; includes codes 047N041, 047N04Z, 047N05Z, 047N06Z, 047N07Z, 047N0D1, 047N0DZ, 047N0EZ, 047N0FZ, 047N0GZ, 047N0Z1, 047N0ZZ, 047N341, 047N34Z, 047N35Z, 047N36Z, 047N37Z, 047N3D1, 047N3DZ, 047N3EZ, 047N3FZ, 047N3GZ, 047N3Z1, 047N3ZZ, 047N441, 047N44Z, 047N45Z, 047N46Z, 047N47Z, 047N4D1, 047N4DZ, 047N4EZ, 047N4FZ, 047N4GZ, 047N4Z1, 047N4ZZ]

047P041-047P4ZZ

Dilation of right anterior tibial artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047P041, 047P04Z, 047P05Z, 047P06Z, 047P07Z, 047P0D1, 047P0DZ, 047P0EZ, 047P0FZ, 047P0GZ, 047P0Z1, 047P0ZZ, 047P341, 047P34Z, 047P35Z, 047P36Z, 047P37Z, 047P3D1, 047P3DZ, 047P3EZ, 047P3FZ, 047P3GZ, 047P3Z1, 047P3ZZ, 047P441, 047P44Z, 047P45Z, 047P46Z, 047P47Z, 047P4D1, 047P4DZ, 047P4EZ, 047P4FZ, 047P4GZ, 047P4Z1, 047P4ZZ]

047Q041-047Q4ZZ

Dilation of left anterior tibial artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047Q041, 047Q04Z, 047Q05Z, 047Q06Z, 047Q07Z, 047Q0D1, 047Q0DZ, 047Q0EZ, 047Q0FZ, 047Q0GZ, 047Q0Z1, 047Q0ZZ, 047Q341, 047Q34Z, 047Q35Z, 047Q36Z, 047Q37Z, 047Q3D1, 047Q3DZ, 047Q3EZ, 047Q3FZ, 047Q3GZ, 047Q3Z1, 047Q3ZZ, 047Q441, 047Q44Z, 047Q45Z, 047Q46Z, 047Q47Z, 047Q4D1, 047Q4DZ, 047Q4EZ, 047Q4FZ, 047Q4GZ, 047Q4Z1, 047Q4ZZ]

047R041-047R4ZZ

Dilation of right posterior tibial artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047R041, 047R04Z, 047R05Z, 047R06Z, 047R07Z, 047R0D1, 047R0DZ, 047R0EZ, 047R0FZ, 047R0GZ, 047R0Z1, 047R0ZZ, 047R341, 047R34Z, 047R35Z, 047R36Z, 047R37Z, 047R3D1, 047R3DZ, 047R3EZ, 047R3FZ, 047R3GZ, 047R3Z1, 047R3ZZ, 047R441, 047R44Z, 047R45Z, 047R46Z, 047R47Z, 047R4D1, 047R4DZ, 047R4EZ, 047R4FZ, 047R4GZ, 047R4Z1, 047R4ZZ]

047S041-047S4ZZ

Dilation of left posterior tibial artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047S041, 047S04Z, 047S05Z, 047S06Z, 047S07Z, 047S0D1, 047S0DZ, 047S0EZ, 047S0FZ, 047S0GZ, 047S0Z1, 047S0ZZ, 047S341, 047S34Z, 047S35Z, 047S36Z, 047S37Z, 047S3D1, 047S3DZ, 047S3EZ, 047S3FZ, 047S3GZ, 047S3Z1, 047S3ZZ, 047S441, 047S44Z, 047S45Z, 047S46Z, 047S47Z, 047S4D1, 047S4DZ, 047S4EZ, 047S4FZ, 047S4GZ, 047S4Z1, 047S4ZZ]

047T041-047T4ZZ

Dilation of right peroneal artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047T041, 047T04Z, 047T05Z, 047T06Z, 047T07Z, 047T0D1, 047T0DZ, 047T0EZ, 047T0FZ, 047T0GZ, 047T0Z1, 047T0ZZ, 047T341, 047T34Z, 047T35Z, 047T36Z, 047T37Z, 047T3D1, 047T3DZ, ,047T3EZ, 047T3FZ, 047T3GZ, 047T3Z1, 047T3ZZ, 047T441, 047T44Z, 047T45Z, 047T46Z, 047T47Z, 047T4D1, 047T4DZ, 047T4EZ, 047T4FZ, 047T4GZ, 047T4Z1, 047T4ZZ]

047U041-047U4ZZ

Dilation of left peroneal artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047U041, 047U04Z, 047U05Z, 047U06Z, 047U07Z, 047U0D1, 047U0DZ, 047U0EZ, 047U0FZ, 047U0GZ, 047U0Z1, 047U0ZZ, 047U341, 047U34Z, 047U35Z, 047U36Z, 047U37Z, 047U3D1, 047U3DZ, 047U3EZ, 047U3FZ, 047U3GZ, 047U3Z1, 047U3ZZ, 047U441, 047U44Z, 047U45Z, 047U46Z, 047U47Z, 047U4D1, 047U4DZ, 047U4EZ, 047U4FZ, 047U4GZ, 047U4Z1, 047U4ZZ]

047V041-047V4ZZ

Dilation of right foot artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047V041, 047V04Z, 047V05Z, 047V06Z, 047V07Z, 047V0D1, 047V0DZ, 047V0EZ, 047V0FZ, 047V0GZ, 047V0Z1, 047V0ZZ, 047V341, 047V34Z, 047V35Z, 047V36Z, 047V37Z, 047V3D1, 047V3DZ, 047V3EZ, 047V3FZ, 047V3GZ, 047V3Z1, 047V3ZZ, 047V441, 047V44Z, 047V45Z, 047V46Z, 047V47Z, 047V4D1, 047V4DZ, 047V4EZ, 047V4FZ, 047V4GZ, 047V4Z1, 047V4ZZ]

047W041-047W4ZZ

Dilation of left foot artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047W041, 047W04Z, 047W05Z, 047W06Z, 047W07Z, 047W0D1, 047W0DZ, 047W0EZ, 047W0FZ, 047W0GZ, 047W0Z1, 047W0ZZ, 047W341, 047W34Z, 047W35Z, 047W36Z, 047W37Z, 047W3D1, 047W3DZ, 047W3EZ, 047W3FZ, 047W3GZ, 047W3Z1, 047W3ZZ, 047W441, 047W44Z, 047W45Z, 047W46Z, 047W47Z, 047W4D1, 047W4DZ, 047W4EZ, 047W4FZ, 047W4GZ, 047W4Z1, 047W4ZZ]

047Y041-047Y4ZZ

Dilation of lower artery [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047Y041, 047Y04Z, 047Y05Z, 047Y06Z, 047Y07Z, 047Y0D1, 047Y0DZ, 047Y0EZ, 047Y0FZ, 047Y0GZ, 047Y0Z1, 047Y0ZZ, 047Y341, 047Y34Z, 047Y35Z, 047Y36Z, 047Y37Z, 047Y3D1, 047Y3DZ, 047Y3EZ, 047Y3FZ, 047Y3GZ, 047Y3Z1, 047Y3ZZ, 047Y441, 047Y44Z, 047Y45Z, 047Y46Z, 047Y47Z, 047Y4D1, 047Y4DZ, 047Y4EZ, 047Y4FZ, 047Y4GZ, 047Y4Z1, 047Y4ZZ]

04CC0ZZ-04CD4ZZ

Extirpation of matter from common iliac artery [right or left, by approach; includes codes 04CC0ZZ, 04CC3ZZ, 04CC4ZZ, 04CD0ZZ, 04CD3ZZ, 04CD4ZZ]

04CE0ZZ-04CF4ZZ

Extirpation of matter from internal iliac artery [right or left, by approach; includes codes 04CE0ZZ, 04CE3ZZ, 04CE4ZZ, 04CF0ZZ, 04CF3ZZ, 04CF4ZZ]

04CH0ZZ-04CJ4ZZ

Extirpation of matter from external iliac artery [right or left, by approach; includes codes 04CH0ZZ, 04CH3ZZ, 04CH4ZZ, 04CJ0ZZ, 04CJ3ZZ, 04CJ4ZZ]

04CK0ZZ-04CL4ZZ

Extirpation of matter from femoral artery [right or left, by approach; includes codes 04CK0ZZ, 04CK3ZZ, 04CK4ZZ, 04CL0ZZ, 04CL3ZZ, 04CL4ZZ]

04CM0ZZ-04CN4ZZ

Extirpation of matter from popliteal artery [right or left, by approach; includes codes 04CM0ZZ, 04CM3ZZ, 04CM4ZZ, 04CN0ZZ, 04CN3ZZ, 04CN4ZZ]

04CP0ZZ-04CQ4ZZ

Extirpation of matter from anterior tibial artery [right or left, by approach; includes codes 04CP0ZZ, 04CP3ZZ, 04CP4ZZ, 04CQ0ZZ, 04CQ3ZZ, 04CQ4ZZ]

04CR0ZZ-04CS4ZZ

Extirpation of matter from posterior tibial artery [right or left, by approach; includes codes 04CR0ZZ, 04CR3ZZ, 04CR4ZZ, 04CS0ZZ, 04CS3ZZ, 04CS4ZZ]

04CT0ZZ-04CU4ZZ

Extirpation of matter from peroneal artery [right or left, by approach; includes codes, 04CT0ZZ, 04CT3ZZ, 04CT4ZZ, 04CU0ZZ, 04CU3ZZ, 04CU4ZZ]

04CV0ZZ-04CW4ZZ

Extirpation of matter from foot artery [right or left, by approach; includes codes 04CV0ZZ, 04CV3ZZ, 04CV4ZZ, 04CW0ZZ, 04CW3ZZ, 04CW4ZZ]

04CY0ZZ-04CY4ZZ

Extirpation of matter from lower artery [by approach; includes codes, 04CY0ZZ, 04CY3ZZ, 04CY4ZZ]

X27H385-X27J3C5

Dilation of femoral artery with sustained release drug-eluting intraluminal device, percutaneous approach, new technology group 5 [right or left, by number of devices; includes codes X27H385, X27H395, X27H3B5, X27H3C5, X27J385, X27J395, X27J3B5, X27J3C5]

X27K385-X27L3C5

Dilation of proximal popliteal artery with sustained release drug-eluting intraluminal device, percutaneous approach, new technology group 5 [right or left, by number of devices; includes codes X27K385, X27K395, X27K3B5, X27K3C5, X27L385, X27L395, X27L3B5, X27L3C5]

X27M385-X27N3C5

Dilation of distal popliteal artery with sustained release drug-eluting intraluminal device, percutaneous approach, new technology group 5 [right or left, by number of devices; includes codes X27M385, X27M395, X27M3B5, X27M3C5, X27N385, X27N395, X27N3B5, X27N3C5]

X27P385-X27Q3C5

Dilation of anterior tibial artery with sustained release drug-eluting intraluminal device, percutaneous approach, new technology group 5 [right or left, by number of devices; includes codes X27P385, X27P395, X27P3B5, X27P3C5, X27Q385, X27Q395, X27Q3B5, X27Q3C5]

X27R385-X27S3C5

Dilation of posterior tibial artery with sustained release drug-eluting intraluminal device, percutaneous approach, new technology group 5 [right or left, by number of devices; includes X27R385, X27R395, X27R3B5, X27R3C5, X27S385, X27S395, X27S3B5, X27S3C5]

X27T385-X27U3C5

Dilation of peroneal artery with sustained release drug-eluting intraluminal devices, percutaneous approach, new technology group 5 [right or left, by number of devices; includes codes X27T385, X27T395, X27T3B5, X27T3C5, X27U385, X27U395, X27U3B5, X27U3C5]

 

 

ICD-10 Diagnosis

 

I70.201-I70.299

Atherosclerosis of native arteries of the extremities

I70.301-I70.799

Atherosclerosis of bypass graft(s) of the extremities

I70.92

Chronic total occlusion of artery of the extremities

I74.3

Embolism and thrombosis of arteries of the lower extremities

I74.5

Embolism and thrombosis of iliac artery

I75.021-I75.029

Atheroembolism of lower extremity

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for all other diagnoses not listed; or when the code describes a procedure or situation designated in the Clinical Indications section as not medically necessary.

Discussion/General Information

Peripheral artery disease (PAD) is an important cause of morbidity that affects up to 10 million people in the United States. It is caused by the restriction of blood flow to the arms, legs, or internal organs due to partial or total occlusion of the blood vessels. There are two types of PAD; organic and functional. Organic PAD, which is the more common form, is due to inflammation and tissue damage in the blood vessels caused by fatty build-up in arteries that blocks normal circulation. Functional PAD is related to abnormal contractions of the blood vessels due to a disease condition (for example, Raynaud's disease). This condition may be triggered by smoking, cold temperatures, emotional stress, or working with vibrating machinery.

PAD affects three major arterial segments of the lower extremity: (1) aorto-iliac arteries, (2) femoro-popliteal (FP) arteries, and (3) infra-popliteal (primarily tibial) arteries. The disease is usually classified based on claudication (a condition characterized by cramping and pain in the leg due to exercise), resting pain, or degree of tissue loss due to chronic ischemia. One measure of the presence and severity of PAD in the extremities is the use of the Ankle Brachial Index (ABI). This test is done by measuring blood pressure at the ankle and in the arms while a person is at rest. The ABI is expressed as a ratio of the highest blood pressure measurement in the foot divided by the highest blood pressure measurement in the arms. A normal ABI is usually 1.0 to 1.4, and lower or higher measurements indicate abnormal blood flow in the extremities. A classification scheme for PAD lesion types has been proposed by the TransAtlantic Inter-Society Consensus (TASC II) working group (Norgren, 2007). This classification system has been accepted and widely used to assess the severity of PAD through consideration of the location, diameter, and length of occlusions. There are several different measurement schemes, based on the location of the occlusion. However, they all rank occlusions from Type A to Type D, with Type A occlusions being the least severe and Type D being the most severe.

More than 70% of individuals diagnosed with PAD remain stable or improve with conservative management. Those who do not improve may undergo a variety of diagnostic studies which may be used in planning for surgery or percutaneous intervention, such as computed tomography angiography (CTA) and magnetic resonance angiography (MRA) (Jens, 2013). Some of these studies also include non-invasive imaging without contrast, which helps to reduce the individual’s exposure to contrast dye. This is especially important in those individuals with significant renal insufficiency. Non-contrast MRA is a reliable alternative to non-invasive imaging with contrast (Wu, 2016). Studies support revascularization for individuals with critical limb ischemia (CLI), a severe obstruction of the arteries that has progressed to the point of severe pain and even skin ulcers or sores in the extremities (Bailey, 2019).

Revascularization procedures used to restore blood flow to the affected limb may involve surgical as well as endovascular approaches. Surgical bypass procedures involve grafting of a native autologous vein or synthetic graft prosthesis from proximal to the area of the affected artery to distal to the affected area, thus ‘bypassing’ the occluded portion of the artery. Due to complications related to bypass surgeries, the use of open and percutaneous endoluminal angioplasty, atherectomy, and stenting have been developed as primary and salvage therapy for PAD. These types of procedures act to reduce the occlusion by compressing or removing the blockage, as opposed to bypassing it.

Procedures such as angioplasty, atherectomy, and stenting have been established as standard procedures for the treatment of lower extremity PAD for many decades; however, in 2018, Katsanos and colleagues published the results of a systematic review and meta-analysis on the risk of death following the application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg. The systematic review yielded 28 randomized controlled trials (RCT) with 4663 participants that were included in the meta-analysis. All-cause participant death up to 1 year was reported by all 28 RCTs with a total of 4432 participants and was similar between paclitaxel-coated devices (58 deaths out of 2506 participants) and control arms (45 deaths out of 1926 participants) (2.3% versus 2.3% crude risk of death; risk ratio, 1.08; 95% confidence interval [CI], 0.72-1.61). Of the 28 RCTs, 12 RCTs with 2316 participants reported on all-cause death at 2 years. A significant difference was found between paclitaxel devices (101 deaths out of 1397 participants) versus control arms (35 deaths out of 919 participants) (7.2% versus 3.8% crude risk of death; risk ratio, 1.68; 95% CI, 1.15-2.47; number-needed-to-harm, 29 patients [95% CI, 19-59]). There were 3 RCTs with 863 participants that reported all-cause death up to 5 years. There were 78 deaths out of 529 participants in the paclitaxel arms versus 27 deaths out of 334 participants in the control arms (14.7% versus 8.1% crude risk of death; risk ratio, 1.93; 95% CI, 1.27-2.93; number-needed-to-harm, 14 patients [95% CI, 9-32]). “Meta-regression showed a significant relationship between exposure to paclitaxel (dose-time product) and absolute risk of death (0.4 ± 0.1% excess risk of death per paclitaxel mg-year; p<0.001)” (Katsanos, 2018). The results of the meta-analysis are concerning; however, as noted by the investigators, the causes of the increased incidence of death are unknown mainly due to most included studies not reporting the actual causes of deaths, which could potentially help determine whether there is a link with paclitaxel devices. Another factor to consider is the paclitaxel arms had greater incidence of participant comorbidities, such as smoking, hyperlipidemia, hypertension, or diabetes mellitus. Further research with cause of death data is needed to validate these results.

In January 2019, the U.S. Food and Drug Administration (FDA) responded to these results by issuing a letter to health care providers on the treatment of peripheral arterial disease with paclitaxel-coated balloons and paclitaxel-eluting stents being potentially associated with increased mortality (FDA, 2019). The letter gave an overview of the meta-analysis and FDA actions, which included evaluation of the data to determine long-term risks associated with paclitaxel-coated devices. The FDA recommended to continue use of paclitaxel-coated devices in accordance with the indications due to the conclusion that the benefits outweigh the risks and to report any adverse events or suspected adverse events.

Also in January 2019, the Society for Cardiovascular Angiography & Interventions (SCAI) released a statement on paclitaxel devices and mortality in relation to an SCAI Vascular Disease Council expert review of the meta-analysis performed by Katsanos and colleagues (2018). The SCAI concluded that “the benefits of paclitaxel devices continue to outweigh any potential risks. However, we strongly encourage our members to discuss the findings of the meta-analysis with their patients and to report any safety concerns to FDA” (SCAI, 2019).

The FDA held a Circulatory System Devices Panel Meeting in June 2019 to review the available information and provide feedback on the late mortality safety signal associated with paclitaxel-coated products used to treat peripheral arterial disease in the femoropopliteal arteries. After the Panel’s review and discussion of the information, the FDA concluded:

FDA analyses of available data from FDA-approved devices show an increase in late mortality (between two and five years) associated with paclitaxel-coated devices intended to treat femoropopliteal disease. However, causality for the late mortality rate increase could not be determined. Additional data may be needed to further assess the magnitude of the late mortality signal, determine any potential causes, identify patient sub-groups that may be at greater risk, and to update benefit-risk considerations of this device class.

Specialty Society Guidance

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) Task Force published their guideline titled, Management of Patients with Peripheral Artery Disease in 2013 (Rooke, 2013). This document updated its guidance and compiled the recommendations from earlier guidelines in 2005 and 2011.

The 2013 ACCF/AHA document supports the use of percutaneous or open exposure angioplasty for individuals with claudication and TASC type A lesions. The document specifically states, “In most claudicant patients being evaluated initially, a 6-month trial of smoking cessation, risk factor modification, exercise, or cilostazol, or a combination, should be initiated before any invasive therapy.”

Please refer to Hirsch (2005) for further details on the ACCF/AHA TASC recommendations (see page e517, Figure 8). The use of these procedures is not supported for more severe lesions.

In 2015, Jaff and others reported an update of the 2007 TASC II classification. This publication reiterated support for the existing TASC II classifications for aortoiliac and femoropopliteal segments, and added a new classification for the infrapopliteal segment. The authors also provided an overview of the current state of evidence addressing various treatment methodologies. They concluded that, despite the years that have passed since the TASC II publication in 2007, there remains a paucity of trial data comparing open and endovascular approaches for the treatment of CLI or claudication.

In 2015 Conte and others representing the Society for Vascular Surgery Lower Extremity Guidelines Writing Group published the Society for Vascular Surgery (SVS) practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. In this document they provide the following recommendations:

Recommendations: Interventions for aortoiliac occlusive disease (AIOD) in intermittent claudication (IC):

5.6. We recommend the use of covered stents for treatment of AIOD in the presence of severe calcification or aneurysmal changes where the risk of rupture may be increased after unprotected dilation.

Recommendations: Intervention for femoropopliteal occlusive disease (FPOD) in intermittent claudication (IC):

5.18. For intermediate-length lesions (5-15 cm) in the SFA, we recommend the adjunctive use of self-expanding nitinol stents (with or without paclitaxel) to improve the midterm patency of angioplasty.
5.20. We recommend against EVT of isolated infrapopliteal disease for IC because this treatment is of unproven benefit and possibly harmful.
5.21. We recommend surgical bypass as an initial revascularization strategy for patients with diffuse FP disease, small caliber (<5 mm), or extensive calcification of the SFA, if they have favorable anatomy for bypass (popliteal artery target, good runoff) and have average or low operative risk.

Additionally, this publication by the SVS also states that, “IC rarely results from isolated profunda femoral disease unless there is associated CFA or SFA disease. Endovascular intervention on the profunda femoral artery for claudication symptoms is of unproven value and may carry substantial risk to this most important source of collateral flow in the limb.”

The American College of Cardiology (ACC) and the American Heart Association (AHA) published a joint guideline on the management of patients with lower extremity peripheral artery disease (Gerhard-Herman, 2016). In this document they provided the following recommendations:

Along with these recommendations, the ACC and AHA provided key components of supervised exercise programs, also referred to as supervised exercise therapy:

In addition to the hospital or outpatient facility, a supervised exercise program may take place in a physician office setting. 

In 2019, the American College of Cardiology Appropriate Use Criteria Task Force, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, and Society for Vascular Medicine issued a joint report on the Appropriate Use Criteria for peripheral artery intervention (Bailey, 2019). In this document, they provided the following recommendations:

Also in 2019, the SVS released joint guidelines with the European Society for Vascular Surgery and the World Federation of Vascular Societies on the management of chronic limb-threatening ischemia (CLTI) (Conte, 2019). Conte and colleagues describe CLTI as a new term that encompasses the full spectrum of individuals with varying degrees of limb-threatening ischemia, including those with a critical level of obstruction of the arteries. The guidelines propose CLTI should be evaluated using two relatively newer staging systems: Global Anatomic Staging System (GLASS) for classifying the pattern of arterial disease in CLTI and Wounds, Ischemia, and foot Infection (WIfI) for staging severity of limb threat. The authors acknowledge that these staging systems are being evaluated in multicenter trials and may require some adjustments. Currently, these staging systems have not been endorsed by most major authoritative organizations. However, the following recommendations were issued:

Further study is needed to validate the new staging systems before they can be broadly used to guide treatment decisions.

Definitions

Angioplasty: A catheter-based procedure involving a percutaneous endovascular approach to access an area of vessel stenosis (obstruction). Balloons within the catheter are sequentially inflated, in order to clear the stenosed lesion within the vessel.

Atherectomy: This term refers to a minimally invasive endovascular technique where atherosclerotic plaque is percutaneously removed from the walls of a blood vessel.

Claudication: A condition characterized by pain in the legs. This condition is usually caused by obstruction of the arteries and commonly triggered by exercise. Claudication can be intermittent, usually caused by exercise, or persistent.

Common iliac artery: A large blood vessel originating at the bifurcation of the descending aorta and ending at the bifurcation into the external and internal iliac arteries.

Critical limb ischemia: Arterial insufficiency with gangrene, a nonhealing ischemic ulcer, or rest pain.

Deep femoral artery (profunda femoris): A branch of the femoral artery that passes closer to the femur than the rest of the femoral artery.

External iliac artery: A branch of the iliac artery that originates at the bifurcation of the common iliac artery and ends where it passes through the pubic tubercle, at which point it is referred to as the femoral artery.

Femoral artery: A major blood vessel in the thigh that originates where the external iliac artery passes through the pubic tubercle. This vessel gives rise to the deep femoral and superficial femoral arteries.

Popliteal artery: A continuation of the superficial femoral artery, beginning where it passes through the distal portion of the adductor magnus muscle, above the knee joint.

Superficial femoral artery: A continuation of the femoral artery after it gives rise to the deep femoral artery. It extends to just above the knee, where it is then referred to as the popliteal artery.

Supervised exercise training: A structured exercise program that is directly supervised by a qualified healthcare provider and takes place in a hospital or outpatient facility in which intermittent walking exercise is used as the treatment modality.

Tibial artery: A continuation of the popliteal artery, beginning below the knee, where it bifurcates into the anterior and posterior tibial arteries.

References

Peer Reviewed Publications:

  1. Katsanos K, Spiliopoulos S, Kitrou P, et al. Risk of death following application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2018; 7(24):e011245.
  2. Jens S, Koelemay MJ, Reekers JA, Bipat S. Diagnostic performance of computed tomography angiography and contrast-enhanced magnetic resonance angiography in patients with critical limb ischaemia and intermittent claudication: systematic review and meta-analysis. Eur Radiol. 2013; 23(11):3104-3114.
  3. Wu G, Yang J, Zhang T, et al. The diagnostic value of non-contrast enhanced quiescent interval single shot (QISS) magnetic resonance angiography at 3T for lower extremity peripheral arterial disease, in comparison to CT angiography. J Cardiovasc Magn Reson. 2016; 18(1):71.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Bachoo P, Thorpe PA, Maxwell H, Welch K. Endovascular stents for intermittent claudication. Cochrane Database Syst Rev. 2010;(1):CD003228.
  2. Bailey SR, Beckman JA, Dao TD, et al. ACC/AHA/SCAI/SIR/SVM 2018 Appropriate Use Criteria for peripheral artery intervention: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, and Society for Vascular Medicine. J Am Coll Cardiol. 2019; 73(2):214–237.
  3. Chowdhury MM, McLain AD, Twine CP. Angioplasty versus bare metal stenting for superficial femoral artery lesions. Cochrane Database Syst Rev. 2014;(6):CD006767.
  4. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019; 69(6S):3S-125S.e40.
  5. Conte MS, Pomposelli FB, Clair DG, et al. Society for Vascular Surgery Lower Extremity Guidelines Writing Group. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg. 2015; 61(3 Suppl):2S-41S.
  6. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol. 2017; 69(11):e71-e126.
  7. Hirsch AT, Haskal ZJ, Hertzer NR, et al.; American Association for Vascular Surgery; Society for Vascular Surgery; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society of Interventional Radiology; ACC/AHA Task Force on Practice Guidelines Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease; American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; Vascular Disease Foundation. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006; 113(11):e463-654.
  8. Jaff MR, White CJ, Hiatt WR, et al.; TASC Steering Committee. An update on methods for revascularization and expansion of the TASC Lesion Classification to include below-the-knee arteries: a supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Endovasc Ther. 2015; 22(5):663-677.
  9. Klein AJ, Jaff MR, Gray BH, et al. SCAI appropriate use criteria for peripheral arterial interventions: an update. Catheter Cardiovasc Interv. 2017; 90(4):E90-E110.
  10. Norgren L, Hiatt WR, Dormandy JA, et al.; TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007; 45 Suppl S:S5-67.
  11. Rooke TW, Hirsch AT, Misra S, et al.; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society for Vascular Medicine; Society for Vascular Surgery. 2011 ACCF/AHA Focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011; 58(19):2020-2045.
  12. Rooke TW, Hirsch AT, Misra S, et al.; American College of Cardiology Foundation Task Force; American Heart Association Task Force. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013; 61(14):1555-1570.
  13. Society for Cardiovascular Angiography and Intervention (SCAI). President’s Pages. SCAI statement on paclitaxel devices and mortality. Last updated: January 25, 2019. Available at: http://www.scai.org/Presidents.aspx?cid=6c89c9f0-57e6-444f-a89c-71effd4e7f4a#.XTpTAU2ouUm. Accessed on July 10, 2020.
  14. U.S. Food and Drug Administration (FDA). Circulatory System Devices Panel of the Medical Devices Advisory Committee. Paclitaxel-coated drug coated balloon and drug-eluting stent late mortality executive summary. Last updated: June 20, 2019. Available at: https://www.fda.gov/media/127698/download. Accessed on July 10, 2020.
  15. U.S. Food and Drug Administration (FDA). Letters to Health Care Providers. Update: treatment of peripheral arterial disease with paclitaxel-coated balloons and paclitaxel-eluting stents potentially associated with increased mortality - letter to health care providers. Last updated: August 7, 2019. Available at: https://www.fda.gov/medical-devices/letters-health-care-providers/update-treatment-peripheral-arterial-disease-paclitaxel-coated-balloons-and-paclitaxel-eluting. Accessed on July 10, 2020.
Index

Angioplasty
Atherectomy
Endarterectomy
Femoropopliteal
Stenting

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

  12/16/2020 Updated Coding section with 01/01/2021 CPT changes; added 0620T.

Reviewed

08/13/2020

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Description, Definitions, Discussion, and References sections. Reformatted Coding section.

Reviewed

08/22/2019

MPTAC review. Updated Discussion and References sections. Updated Coding section with 10/01/2019 ICD-10-PCS code changes.

Revised

06/06/2019

MPTAC review. In the Clinical Indications section, changed “exercise” to “activity” in the MN statement regarding the absence of other conditions in the treatment of claudication, and changed “TASC type A of the common iliac, external iliac, or superficial femoral arteries, defined as follows” to “has one of the following anatomic characteristics” in the MN statement regarding targeted lesions. Revised the formatting in the Clinical Indications section. Updated Discussion, Definitions, and References sections.

Revised

07/26/2018

MPTAC review. Clarified the TASC A lesion definitions in the MN statement regarding treatment of claudication with angioplasty. Changed “femoropopliteal” to “superficial femoral artery” in the MN statement regarding treatment of claudication with angioplasty. Revised the MN statement regarding primary stent placement to clarify the length of intermediate-length stenosis or occlusion to be 5-15 cm. Revised the NMN statement for primary stent placement to clarify the type of lesions addressed. Clarified NMN statement for use of endovascular procedures for CLI. Added Definitions section.

 

07/01/2018

Updated Coding section with 07/01/2018 CPT changes; added CPT 0505T.

Revised

03/22/2018

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Added the use of either percutaneous or open exposure primary stent placement is considered medically necessary for intermediate-length lesions of the femoropopliteal artery. Added new MN statement addressing the use of covered stent devices for claudication due to aortoiliac occlusive disease (AIOD). Added “claudication due to isolated infrapopliteal artery disease” to NMN statement. Updated Discussion and References sections.

Reviewed

08/03/2017

MPTAC review. Updated References section. Updated Coding section with 10/01/2017 ICD-10-PCS procedure code changes.

Revised

11/03/2016

MPTAC review. Updated formatting in the Clinical Indications section. Clarified NM statement regarding individuals with claudication and use of stents or atherectomy devices as salvage. Updated Rationale and References sections.

 

10/01/2016

Updated Coding section with 10/01/2016 ICD-10-PCS procedure code changes.

Revised

11/05/2015

MPTAC review. Revised medical necessary statement addressing the use of either percutaneous or open exposure angioplasty to change the requirement of 3 months conservative treatment to 6 months, and added clarification for what comprises conservative treatment. Removed ICD-9 codes from Coding section.

New

08/06/2015

MPTAC review. Initial document development.


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