Abdominal Aortic Aneurysm

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.

Iliac Artery Aneurysm

Endovascular stent grafting for iliac artery aneurysms (34808, 34820, 34825, 34826, 34900) and associated radiology services (75954) are eligible for payment.

Thoracic Aortic Aneurysm

Endovascular stent grafting for descending thoracic aortic aneurysms (0033T-0037T) and associated radiology services (0038T-0040T) are eligible for payment when treating aneurysms of 23-37 mm of inner aortic diameter, and when using an FDA-approved endoprosthesis, e.g., GORE TAG.

Endovascular stent grafts are considered investigational for the treatment of thoracic aortic arch aneurysms or aortic dissections (37799). A participating, preferred, or network provider can bill the member for the denied service.

Description

Abdominal Aortic Aneurysm

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).

Iliac Artery Aneurysm

Isolated iliac arterial aneurysms are infrequent, accounting for less than 1% of peripheral arterial aneurysms. The most common cause is atherosclerosis, but they are also associated with conditions such as pregnancy, infection, postoperative injury, dissection, trauma, Marfan syndrome, and other collagen vascular diseases. Men are affected more commonly than women. The frequency of iliac aneurysms increases with age. The location of iliac artery aneurysms in the pelvis makes them difficult to detect by physical examination. The increasing use of abdominal imaging studies has resulted in more frequent detection of small and asymptomatic iliac aneurysms. Iliac aneurysms are more frequently found in the common iliac, followed by the internal iliac artery, and rarely in the external iliac. Up to 50% are bilateral.

The vast majority of patients with iliac aneurysms are asymptomatic, but some may present with symptoms due to local compression of adjacent pelvic structures, thrombosis, embolism or rupture. These symptoms are usually related to gastrointestinal, genitourinary, neurologic, or venous obstruction or compression. Because of their low incidence, the natural history of these aneurysms is not well defined. Overall, the prognosis of patients with untreated iliac artery aneurysms is poor. A ruptured iliac aneurysm is associated with increased rates of morbidity and mortality.

A nonsurgical treatment of isolated iliac artery aneurysms and traumatic iliac disruptions provides an alternative before surgery is considered. Endoluminal treatment of these aneurysms offers the potential to avoid many of the complications associated with open repair and general anesthesia. It is a less-invasive procedure that results in less blood loss, shorter recovery time, and shorter hospital stay.

Thoracic Aortic Aneurysm

Aortic dissection can be subdivided into Type A, which involves the aortic arch, and Type B, which is confined to the descending aorta. Type A dissections are usually treated surgically, while Type B dissections are usually treated medically, with surgery indicated for serious complications, such as visceral ischemia, impending rupture, intractable pain, or sudden reduction in aortic size. Dissections associated with obstruction and ischemia can also be subdivided into an obstruction caused by an intimal tear at branch vessel orifices, or by compression of the true lumen by the pressurized false lumen. It has been proposed that endovascular therapy can repair the latter group of dissections by redirecting flow into the true lumen.

The traditional standard therapy for thoracic aortic aneurysm is open surgical repair with graft replacement of the diseased segment. This requires lateral thoracotomy, use of cardiopulmonary bypass, long surgical hours, and a variety of peri- and post-operative complications, with spinal cord ischemia considered the most devastating.

An alternative to the traditional therapy is endovascular stent grafting.

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

National Blue Cross Blue Shield Medical Policy 7.01.86, Endovascular Stent Grafts for Thoracic Aortic Aneurysms or Dissections