Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-115
Topic: Intravascular Ultrasound (IVUS)
Effective Date: August 6, 2007
Issued Date: August 6, 2007
Date Last Reviewed: 07/2007

General Policy Guidelines

Indications and Limitations of Coverage

Coronary Vessels
Intravascular ultrasound (IVUS) of a coronary vessel or graft (codes 92978 and 92979) is eligible for payment when performed with an approved diagnostic evaluation and/or therapeutic intervention. The allowance for IVUS includes all transducer manipulations and repositioning within the specific vessel being examined both before and after therapeutic intervention (e.g., stent placement).

However, if the angioplasty, atherectomy, or placement of a stent is not eligible for payment, or if the intravascular ultrasound is performed independently, then the intravascular ultrasound is not covered. A participating, preferred, or network provider can bill the member for the denied service.

Non-coronary Vessels
Intravascular ultrasound (IVUS) of non-coronary vessels (codes 37250, 37251, 75945, 75946) is eligible when performed in conjunction with a vascular interventional procedure. If the vascular procedure is not eligible for payment, or if the intravascular ultrasound is performed independently, then the intravascular ultrasound is not covered. A participating, preferred, or network provider can bill the member for the denied service.

Date Last Reviewed:  05/2005

Refer to Medical Policy Bulletin S-82 for additional information on Intra-Arterial/Intravenous Therapeutic Procedures.

Refer to Medical Policy Bulletin S-95 for information on Percutaneous Transluminal Atherectomy.

Refer to Medical Policy Bulletin S-105 for information on Intracoronary Stents.

Description

Intravascular ultrasound is an imaging technique in which a miniaturized ultrasound transducer and rotational mirror are mounted on the tip of a catheter and inserted directly into an artery or vein to produce two-dimensional tomographic images or three dimensional computer-enhanced reconstructions of planar IVUS images. Intravascular ultrasound is intended to image the internal lining of coronary and non-coronary vessels prior to, during, and following procedures, including but not limited to angioplasty, atherectomy, or placement of a stent.

Procedure Codes

372503725175945759469297892979

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Evaluating Intermediate Coronary Lesions in the Cardiac Catheterization Laboratory, Reviews in Cardiovascular Medicine, 2003, Winter

Intravascular Ultrasound-Guided Renal Artery Stenting, Journal of Endovascular Therapy, Vol. 8, No. 3

Expanding Options for Bedside Placement of Inferior Vena Cava Filters with Intravascular Ultrasound when Transabdominal Duplex Ultrasound Imaging is Inadequate, Ann Vasc Surg, 2004, 18 (3):329-34

Guidance of Interventions in Subintimal Recanalization and Fenestration of Dissection Membranes Using a Novel Dual-lumen Intravascular Ultrasound Catheter, Rofo, 2006, Sep: 178 (9): 898-905

Intravascular Ultrasound Assessment of Atherosclerotic Plaque in the Aorta, Int J Cardio, 3/29/2007

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[Version 001 of S-115]

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Procedure Code Attachment


Glossary




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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.