Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting and Extracranial- Intracranial (EC-IC) Arterial Bypass Surgery
Policy #:MA11.056e

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

Percutaneous transluminal angioplasty (PTA) is considered medically necessary and, therefore, covered when the following criteria are met.

PTA FOR THE TREATMENT OF ATHEROSCLEROTIC OBSTRUCTIVE LESIONS NCD 20.7
  • PTA for the treatment of the lower extremities (i.e., the iliac, femoral, and popliteal arteries) or for the upper extremities (i.e., the innominate [the artery that supplies blood to the right arm and head and neck], subclavian, axillary, and brachial arteries); "upper extremities" do not include head or neck vessels.
  • PTA for the treatment of a single coronary artery for individuals for whom the likely alternative treatment is coronary bypass surgery and who exhibit all of the following characteristics:
    • Angina refractory to optimal medical management
    • Objective evidence of myocardial ischemia
    • Lesions amenable to angioplasty
  • PTA for the treatment of the renal arteries for individuals in whom there is an inadequate response to thorough medical management of symptoms and for whom surgery is the likely alternative. PTA for this group of individuals is an alternative to surgery, not simply an addition to medical management.
  • PTA for the treatment of arteriovenous dialysis fistulas and grafts when performed through either a venous or an arterial approach.

PTA OF THE CAROTID ARTERY CONCURRENT WITH CAROTID ARTERY STENT (CAS) PLACEMENT IN FDA-APPROVED POST-APPROVAL STUDIES NCD 20.7
Coverage of PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent and an FDA-approved or FDA-cleared embolic protection device for an FDA-approved indication, when furnished in accordance with FDA-approved protocols governing post-approval studies, is considered medically necessary and, therefore, covered.

PTA OF THE CAROTID ARTERY CONCURRENT WITH CAS PLACEMENT IN INDIVIDUALS AT HIGH RISK FOR CAROTID ENDARTERECTOMY (CEA) NCD 20.7
PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent with FDA-approved or FDA-cleared embolic protection is considered medically necessary and, therefore, covered for the following indication:
  • Individuals who are at high risk for CEA and who also have symptomatic carotid artery stenosis equal to or greater than 70 percent.
    • Symptoms of carotid artery stenosis include carotid transient ischemic attack (distinct focal neurological dysfunction persisting less than 24 hours), focal cerebral ischemia producing a nondisabling stroke (modified Rankin scale less than three with symptoms for 24 hours or more), and transient monocular blindness (amaurosis fugax). Individuals who have had a disabling stroke (modified Rankin scale greater than three) shall be excluded from coverage.

The use of an FDA-approved or FDA-cleared embolic protection device is required. If deployment of the embolic protection device is not technically possible, and not performed, then the procedure is not covered by the Company because it is service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

The degree of carotid artery stenosis shall be measured by duplex Doppler ultrasound or carotid artery angiography and recorded in the individual's medical records. If the stenosis is measured by ultrasound prior to the procedure, then the degree of stenosis must be confirmed by angiography at the start of the procedure. If the stenosis is determined to be less than 70 percent by angiography, CAS should not proceed.

NOT MEDICALLY NECESSARY

EXTRACRANIAL-INTRACRANIAL (EC-IC) ARTERIAL BYPASS SURGERY
Extracranial-intracranial (EC-IC) arterial bypass surgery is considered not medically necessary and, therefore, not covered when performed as a treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries, including the treatment or prevention of strokes.

EXPERIMENTAL/INVESTIGATIONAL

PTA OF THE CAROTID ARTERY CONCURRENT WITH CAS IN FDA-APPROVED CATEGORY B INVESTIGATIONAL DEVICE EXEMPTION (IDE) CLINICAL TRIALS
PTA of the carotid artery performed for carotid artery dilation concurrent with carotid stent placement, using a Category B IDE, is considered experimental/investigational and, therefore, not covered; except for the following indications:
  • Coverage in a qualifying clinical trial approved by Original Medicare, using a category B IDE, for individuals who are at high risk for CEA and have symptomatic carotid artery stenosis between 50 percent and 70 percent. Coverage is limited procedures performed using FDA-approved CAS and FDA-approved or FDA-cleared embolic protection devices.
    • Symptoms of carotid artery stenosis include carotid transient ischemic attack (distinct focal neurological dysfunction persisting less than 24 hours), focal cerebral ischemia producing a nondisabling stroke (modified Rankin scale less than three with symptoms for 24 hours or more), and transient monocular blindness (amaurosis fugax). Individuals who have had a disabling stroke (modified Rankin scale equal to or greater than three) shall be excluded from coverage.
  • Coverage in a qualifying clinical trial approved by Original Medicare, using a category B IDE, for individuals who are at high risk for CEA and have asymptomatic carotid artery stenosis equal to or greater than 80 percent. Coverage is limited procedures performed using FDA-approved CAS and FDA-approved or FDA-cleared EPS.

PTA OF THE INTRACRANIAL ARTERY CONCURRENT WITH INTRACRANIAL STENT PLACEMENT IN FDA-APPROVED CATEGORY B IDE CLINICAL TRIALS
PTA with stenting of the intracranial arteries for the treatment of cerebral artery stenosis equal to or greater than 50 percent in individuals with intracranial atherosclerotic disease is considered experimental/investigational and, therefore, not covered, with the following exception:
  • Coverage in a qualifying clinical trial approved by Original Medicare, using a category B IDE device performed for PTA and stenting of intracranial arteries for the treatment of cerebral artery stenosis equal to or greater than 50 percent in individuals with intracranial atherosclerotic disease.

COVERAGE OF CLINICAL TRIALS

Coverage for routine costs associated with qualifying clinical trials for Medicare Advantage members who are enrolled in a clinical trial approved by Medicare are processed through the local Medicare Administrative Contractor (MAC). Therefore:
  • Providers must submit all claims for routine costs associated with qualifying clinical trials to the local MAC.
  • Claims received by the Company for routine costs associated with qualifying clinical trials, including FDA-approved prescription pharmaceuticals, biologics, or devices, are not eligible for reimbursement consideration by the Company.

COVERAGE OF CLINICAL TRIALS USING A CATEGORY B IDE DEVICE:

Professional providers are responsible for checking the CMS Coverage Website to identify whether CMS (or its designated entity) has approved the study for purposes of Medicare coverage prior to billing for the routine costs of a clinical trial and the Category B IDE device. If Original Medicare determines that the device does, in fact, meet the requirements of coverage, and the clinical trial is approved, coverage for the routine costs associated with a qualifying clinical trial and the category B IDE device are processed through the Medicare Advantage plan.

A list of IDE studies meeting CMS’ standards for coverage are listed and maintained on the CMS Coverage website at https://www.cms.gov/Medicare/Coverage/IDE/Approved-IDE-Studies.html.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

Individuals at high risk for carotid endarterectomy (CEA) are defined as having significant comorbidities and/or anatomic risk factors (i.e., recurrent stenosis and/or previous radical neck dissection) and would be poor candidates for CEA. Significant comorbid conditions include but are not limited to:
  • Congestive heart failure (CHF) class III/IV
  • Left ventricular ejection fraction (LVEF) less than 30 percent
  • Unstable angina
  • Contralateral carotid occlusion
  • Recent myocardial infarction (MI)
  • Previous CEA with recurrent stenosis
  • Prior radiation treatment to the neck
  • Other conditions that were used to determine individuals at high risk for CEA in previous carotid artery stenting trials and studies, such as ARCHER, CABERNET, SAPPHIRE, BEACH, and MAVERIC II

MODIFIED RANKIN SCALE (mRS) FOR STROKES
    0 - No symptoms.
    1 - No significant disability. Able to carry out all usual activities, despite some symptoms.
    2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.
    3 - Moderate disability. Requires some help, but able to walk unassisted.
    4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.
    5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent.
    6 - Dead

BENEFIT APPLICATION

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

Subject to the terms and conditions of the applicable Evidence of Coverage, percutaneous transluminal angioplasty (PTA) is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary or as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Description

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA)

Percutaneous transluminal angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. With the development and use of balloon angioplasty for treatment of atherosclerotic and other vascular stenoses, PTA (with and without the placement of a stent) is a widely used technique for dilating lesions of peripheral, coronary, renal, and arteriovenous dialysis fistula and grafts.

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA) CONCURRENT WITH CAROTID ARTERY STENTING (CAS)

For individuals at high risk for carotid endarterectomy (CEA), defined as having significant comorbidities and/or anatomic risk factors, CAS may be performed. For CAS, a catheter is usually inserted through the femoral artery, and threaded up to the carotid artery beyond the area of narrowing. A distal embolic protection device or filter is usually placed first to catch emboli or debris that may dislodge during the procedure. A self-expandable or balloon-expandable, metal mesh stent is then placed to widen the stenosis and the protection device is removed.

EXTRACRANIAL-INTRACRANIAL (EC-IC) ARTERIAL BYPASS SURGERY

Extracranial-intracranial (EC-IC) arterial bypass surgery is a procedure whose premise is to bypass narrowed arterial segments to improve the blood supply to the brain and reduce the risk of having a stroke, However, the procedure has not been demonstrated to be any more effective than no surgical intervention. Accordingly, EC-IC arterial bypass surgery has not been shown to be effective for the treatment of ischemic cerebrovascular disease of the carotid or middle cerebral arteries.

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA) AND INTRACRANIAL STENTING

Intracranial artery stenosis causes approximately eight to ten percent of ischemic cerebrovascular accidents (CVAs or strokes) by restricting blood flow and/or causing embolism. The most common treatment is the use of blood thinners such as antiplatelets (e.g., aspirin) or anticoagulants (e.g., Coumadin®). Intracranial PTA and stenting is a relatively novel approach for the treatment of refractory, symptomatic intracranial artery stenosis who either continue to have symptoms of a transient ischemic attack (TIA) or develop a CVA while on treatment with antithrombotic medications.

INVESTIGATIONAL DEVICE EXEMPTION (IDE)

An IDE is a regulatory submission that permits clinical investigation of devices. An IDE allows the device to be used in a clinical study in order to collect data on safety and effectiveness that is required to support a Premarket Approval (PMA) application, an HDE, or a Premarket Notification [510(k)] submission to the FDA. Investigational use also includes clinical evaluation of certain modifications or new intended uses of legally marketed devices.
References

Centers for Medicare & Medicaid Services (CMS). Carotid artery stenting facilities. [CMS Web site]. 09/05/2014. Available at: http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/Carotid-Artery-Stenting-Facilities.html. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System.Pub 100-03: Medicare National Coverage Determinations. Transmittal 77: Percutaneous transluminal angioplasty (PTA). [CMS Website]. 09/12/07. Available at: http://www.cms.hhs.gov/transmittals/downloads/R77NCD.pdf. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). Decision memo for carotid artery stenting (CAG-00085R). [CMS Web site]. 03/17/05. Available at: https://www.cms.gov/medicare-coverage-database/details/nca-details.aspx?NCAId=157&DocID=CAG-00085R&id=157&bc=gAAAABAAAAAA&. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). Decision memo for intracranial stenting and angioplasty (CAG-00085R5). [CMS Web site]. 05/12/08. Available at: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=214&fromdb=true. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). Decision memo for percutaneous transluminal angioplasty (PTA) of the carotid artery concurrent with stenting (CAG-00085R7). [CMS Web site]. 12/09/09. Available at: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=230&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7CCAL%7CNCD%7CMEDCAC%7CTA%7CMCD&ArticleType=SAD%7CEd&PolicyType=Final&s=-%7C5%7C6%7C66%7C67%7C44&KeyWord=percutaneous+transluminal+angioplasty+(PTA)+with+intracranial+stent+placement&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAgEAAA%3D%3D& Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). General Information. Carotid artery stenting (CAS) investigational studies. [CMS Web site]. 09/07/2016. Available at:https://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/Carotid-Artery-Stenting-CAS-Investigational-Studies.html. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 310.1: Routine costs in clinical trials. [CMS Web site]. 10/09/2007. Available at:
https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=1&ncdver=2&DocID=310.1&bc=gAAAAAgAAAAAAA%3d%3d&. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare coverage related to investigational device (IDE) studies. Approved IDE studies. [CMS Web site]. 08/04/2015. Available at: https://www.cms.gov/Medicare/Coverage/IDE/Approved-IDE-Studies.html. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare coverage related to investigational device exemption (IDE) studies. [CMS Web site]. 12/13/2017. Available at: https://www.cms.gov/medicare/coverage/IDE/index.html. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare coverage related to investigational device exemption (IDE) studies. Pivotal study of the MicroVention, Inc. Carotid Artery Stent System used in conjunction with the Nanoparasol® Embolic Protection System for the treatment of carotid artery stenosis in patients at elevated risk for adverse events from carotid endarterectomy.(CONFIDENCE Trial). [CMS Web site]. 07/07/2016. Available at:
https://www.cms.gov/Medicare/Coverage/IDE/Approved-IDE-Studies-Items/G140249-NCT02657707-.html?DLPage=1&DLEntries=10&DLFilter=Carotid%20artery%20%20&DLSort=2&DLSortDir=ascending. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.2: Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery. [CMS Web site]. 03/27/1991. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?MCDId=17&ExpandComments=n&McdName=Clinical+Pharmacology+Compendium+Revision+Request+-+CAG-00392&mcdtypename=Compendia&MCDIndexType=6&NCDId=54&ncdver=1&bc=AgAEAAAAAgAA&. Accessed January 09, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.7: Percutaneous transluminal angioplasty (PTA). [CMS Web site]. Revised: 03/11/2013. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=201&ncdver=10&CoverageSelection=National&KeyWord=percutaneous+transluminal+angioplasty&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAAAA%3d%3d&. Accessed January 09, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

37215, 37218, 37220, 37221, 37222, 37223, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37232, 37233, 37234, 37235, 37246, 37247, 92920, 92921, 92924, 92925, 92928, 92929, 92933, 92934, 92937, 92938, 92941, 92943, 92944


NOT MEDICALLY NECESSARY
37216, 61711


EXPERIMENTAL/INVESTIGATIONAL
61630, 61635



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

I63.031 Cerebral infarction due to thrombosis of right carotid artery

I63.032 Cerebral infarction due to thrombosis of left carotid artery

I63.039 Cerebral infarction due to thrombosis of unspecified carotid artery

I63.131 Cerebral infarction due to embolism of right carotid artery

I63.132 Cerebral infarction due to embolism of left carotid artery

I63.139 Cerebral infarction due to embolism of unspecified carotid artery

I63.211 Cerebral infarction due to unspecified occlusion or stenosis of right vertebral artery

I63.212 Cerebral infarction due to unspecified occlusion or stenosis of left vertebral artery

I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries

I63.219 Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral artery

I63.22 Cerebral infarction due to unspecified occlusion or stenosis of basilar artery

I63.29 Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries

I63.231 Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries

I63.232 Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries

I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries

I63.239 Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery

I63.511 Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery

I63.512 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery

I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries

I63.521 Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery

I63.522 Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery

I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries

I63.531 Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery

I63.532 Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery

I63.533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior cerebral arteries

I63.541 Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery

I63.542 Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery

I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries

I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery

I65.01 Occlusion and stenosis of right vertebral artery

I65.02 Occlusion and stenosis of left vertebral artery

I65.03 Occlusion and stenosis of bilateral vertebral arteries

I65.09 Occlusion and stenosis of unspecified vertebral artery

I65.1 Occlusion and stenosis of basilar artery

I65.21 Occlusion and stenosis of right carotid artery

I65.22 Occlusion and stenosis of left carotid artery

I65.23 Occlusion and stenosis of bilateral carotid arteries

I65.29 Occlusion and stenosis of unspecified carotid artery

I66.01 Occlusion and stenosis of right middle cerebral artery

I66.02 Occlusion and stenosis of left middle cerebral artery

I66.03 Occlusion and stenosis of bilateral middle cerebral arteries

I66.09 Occlusion and stenosis of unspecified middle cerebral artery

I66.11 Occlusion and stenosis of right anterior cerebral artery

I66.12 Occlusion and stenosis of left anterior cerebral artery

I66.13 Occlusion and stenosis of bilateral anterior cerebral arteries

I66.19 Occlusion and stenosis of unspecified anterior cerebral artery

I66.21 Occlusion and stenosis of right posterior cerebral artery

I66.22 Occlusion and stenosis of left posterior cerebral artery

I66.23 Occlusion and stenosis of bilateral posterior cerebral arteries

I66.29 Occlusion and stenosis of unspecified posterior cerebral artery

I66.3 Occlusion and stenosis of cerebellar arteries

I66.8 Occlusion and stenosis of other cerebral arteries

I66.9 Occlusion and stenosis of unspecified cerebral artery

I67.2 Cerebral atherosclerosis

I67.82 Cerebral ischemia

I67.858 Other hereditary cerebrovascular disease



HCPCS Level II Code Number(s)



Healthcare Common Procedure Coding System (HCPCS) C Series Codes can only be reported for outpatient facility services. Professional providers should not report HCPCS C Series Codes for professional services regardless of where those services are performed

C1884 Embolization protective system


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

Revisions from MA11.056e:
12/18/2019This policy has been reissued in accordance with the Company's annual review process.
10/01/2018The following ICD-10 CM narratives have been revised in this policy:

I63.219

FROM: Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral artery

I63.239
FROM: Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery

The following ICD-10 CM code has been added to this policy:
I67.858 Other hereditary cerebrovascular disease

Revisions from MA11.056d:
01/31/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on percutaneous transluminal angioplasty (PTA) concurrent with or without stenting and extracranial- intracranial (EC-IC) arterial bypass surgery
11/22/2017This policy has been reissued in accordance with the Company's annual review process.
10/01/2017This version of the policy will become effective 10/01/2017.

The following ICD-10 CM narratives have been revised in this policy:

I63.211:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of right vertebral arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of right vertebral artery

I63.212:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of left vertebral arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of left vertebral artery


I63.22:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of basilar artery


I63.513:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries


I63.523:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries


I63.533:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior cerebral arteries

Revisions from MA11.056c:
01/01/2017This version of the policy will become effective 01/01/2017.

The following CPT codes have been deleted from this policy:
35471, 35472, 35475, 35476

The following CPT codes have been added to this policy:
37246, 37247

Revisions from MA11.056b:
10/01/2016This version of the policy will become effective 10/01/2016.

The intent of this policy remains unchanged; however, statement revised for coverage of clinical trials using a category B investigation device exemption (IDE).

This policy has been identified for the ICD-10 CM code update, effective 10/01/2016.

The following ICD-10 CM codes have been added to this policy (Medically necessary):

I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries
I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries
I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle arteries
I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior arteries
I63.533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior arteries
I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries

The following CPT codes have been removed from this policy, since they are not clinically appropriate for the scope of this policy:

0075T
0076T

The following ICD-10 CM codes have been removed from this policy, since they are not clinically appropriate for the scope of this policy:

I63.20 Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries
I65.8 Occlusion and stenosis of other precerebral arteries
I65.9 Occlusion and stenosis of unspecified precerebral artery

The following Modifiers have been removed from this policy since they are informational only:

LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LM Left main coronary artery
RC Right coronary artery
RI Ramus intermedius coronary artery

The following ICD-10 CM code has been added to this policy:

I66.19 Occlusion and stenosis of unspecified anterior cerebral artery

The following HCPCS Level II code has been added to this policy:

C1884 Embolization protective system

MA11.056a
10/02/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Transluminal Angioplasty (PTA) and Extracranial (EC) and Intracranial (IC) Arterial Bypass Surgery.
10/01/2015Applicable ICD-10 CM codes have been added to the policy.

MA11.056
01/01/2015This is a new policy. This policy has been identified for the CPT code update, effective 01/01/2015.

The following CPT code has been added to the policy: 37218

The following CPT narratives have been revised in the policy: 0075T, 0076T, 37215, 37216





Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: 12/19/2019