Endovascular stent-grafting for abdominal aortic aneurysms (34800-34834) and associated radiological services (75952, 75953) are considered eligible for payment when performed as treatment for the following indications:

• aneurysms measuring 5.0 centimeters or greater, or
• aneurysms measuring 4.5 to 5.0 that are rapidly expanding or are symptomatic

Endovascular stent grafting reported for any other indications is considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Codes 0078T-0081T also represent placement and radiological guidance of an endovascular stent-graft. However, these specific procedures are more complex and are still being performed in clinical trial settings with no long-term outcomes available. Therefore, codes 0078T-0081T are considered experimental/investigational. They are not covered.

Description

An aneurysm is an abnormal condition characterized by the dilatation of a portion of the wall of an artery. The aorta, the largest blood vessel in the body, is particularly susceptible to aneurysm formation. When an aortic aneurysm enlarges and ruptures, it usually results in fatal internal bleeding.

Conventional management of significant abdominal aortic aneurysms consists of major, open abdominal surgery to implant a graft and prevent the aneurysm from rupturing. However, there is a minimally invasive, catheter-based alternative to open surgery called endovascular stent-grafting (34800-34834). To prepare for this procedure, accurate assessment of aneurysm dimensions and structure is critical for successful treatment. Measurements are needed of the aneurysm in order to select or construct the appropriate size stent-graft.

Endovascular stent-grafting is a technique in which the catheter is inserted through the femoral artery and advanced into the abdominal aorta. The stent-graft is then positioned within the aneurysm via the catheter in order to provide an alternative pathway for blood to flow through the aorta without filling the aneurysm. This reduces pressure on the aneurysm with the intent of preventing it from rupturing. Radiological guidance is required to accomplish this procedure (75952, 75953).

NOTE:

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 circumstances may warrant individual consideration, based on review of applicable medical records.

PRN References

02/2000, Endovascular stent-grafts for abdominal aortic aneurysm
12/2000, Blue Shield approves coverage for endovascular stent-graft for abdominal aortic aneurysm

Endovascular Grafts for Abdominal Aortic Aneurysms, Consortium Health Plans, Inc., Policy 7.01.67, 9/30/98

Distal Migration of Stent-Grafts After Endovascular Repair of Abdominal Aortic Aneurysms, Journal of Vascular Interventional Radiology, Volume 10, Issue 3, March 1999

Fatal Late Multiple Emboli After Endovascular Treatment of Abdominal Aortic Aneurysm, Internal Angiology, Volume 17, Issue 4, December 1998

Abdominal Aortic Aneurysm in High-Risk Patients: Short-to-Intermediate-Term Results of Endovascular Repair, Radiology, Volume 210, Issue 2, February 1999

Endoleak After Stent-Graft Treatment of Abdominal Aortic Aneurysm, British Journal of Surgery, Volume 86, Issue 5, May 1999

Abdominal Aortic Aneurysm - A Six-Year Comparison of Endovascular Versus Transabdominal Repair, Annals of Surgery, Volume 230, Number 3, September 1999

AneuRx Stent Graft Versus Open Surgical Repair of Abdominal Aortic Aneurysms: Multicenter Prospective Clinical Trial, Journal of Vascular Surgery, February 1999

Patient Selection for Endovascular Repair of Abdominal Aortic Aneurysms: Changing the Threshold for Intervention, Seminars in Vascular Surgery, Volume 12, Number 3, September 1999

Early Complications and Endoleaks after Endovascular Abdominal Aortic Aneurysm Repair: Report of a Multicenter Study, Journal of Vascular Surgery, Volume 31, Number 1, January 2000

Aortoduodenal Fistula after Endovascular Stent-Graft of an Abdominal Aortic Aneurysm, Journal of Vascular Surgery, Volume 31, Number 1, January 2000