Notification

Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound


Notification Issue Date: 04/01/2019

Note: on 04/04/2019 the Notification Issue Date was corrected from 07/01/2019 to 04/01/2019.

This version of the policy will become effective 07/01/2019.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Arterial Ultrasound . These guidelines will become effective 07/01/2019. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Cardiology.html.



Medicare Advantage Policy

Title:Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound
Policy #:MA11.113b

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.

The intent of this policy is to communicate that the Company has delegated the responsibility for utilization management activities for percutaneous coronary intervention, coronary angiography and arterial ultrasound to AIM Specialty Health (AIM).

The Company’s position that percutaneous coronary intervention, coronary angiography and arterial ultrasound are considered not medically necessary when they are used for conditions not covered by Medicare in accordance with CMS guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no there is no Medicare coverage determination, the Company uses AIM Clinical Appropriateness Guidelines to determine medical necessity. When percutaneous coronary intervention, coronary angiography and arterial ultrasound are used for conditions that are not addressed in the AIM Clinical Appropriateness Guidelines they are considered not medically necessary.

Please refer to the References section of this policy for a link to the entire AIM Clinical Appropriateness Guidelines for percutaneous coronary intervention, diagnostic coronary angiography, and arterial ultrasound that are part of this program. Refer to Attachment A of this policy for a complete list of codes for percutaneous coronary intervention, coronary angiography and arterial ultrasound services.

The Company has delegated the responsibility for utilization management for the following, percutaneous coronary intervention, diagnostic coronary angiography and arterial ultrasound through AIM. To determine medical necessity for these services, AIM first utilizes Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no Medicare guidelines exist, AIM will utilize their Clinical Appropriateness Guidelines.

PERCUTANEOUS CORONARY INTERVENTION
  • Percutaneous transluminal coronary artery angioplasty
  • Percutaneous transcatheter intracoronary stent placement
  • Percutaneous transluminal coronary atherectomy

When percutaneous coronary intervention is part of another outpatient procedure, the percutaneous coronary intervention will be managed through AIM; irrespective of the utilization management requirements for the other outpatient procedure. Percutaneous coronary intervention services that are performed on an emergent basis are not part of the utilization management program.

DIAGNOSTIC CORONARY ANGIOGRAPHY

Diagnostic coronary angiography of native coronary arteries or bypass grafts, whether or not the angiographic procedure is performed in conjunction with right and/or left heart catheterization

For computed tomography angiography (CTA) and Coronary artery CTA (CCTA) refer to AIM Diagnostic Imaging Clinical Appropriateness Guidelines.

ARTERIAL ULTRASOUND
  • Duplex ultrasound imaging of the aorta, inferior vena cava and iliac vessels
  • Duplex ultrasound imaging of the extracranial arteries
  • Duplex ultrasound imaging of the arteries of the lower extremities
  • Duplex ultrasound imaging of the arteries of the upper extremities
  • Physiologic testing for peripheral arterial disease (PAD) of the upper and lower extremities*

* Physiologic testing includes the non-invasive evaluation of the peripheral circulation based on measurement of limb blood pressure with pulse volume recordings or Doppler waveforms, or other parameters without utilizing data from direct imaging of the blood vessels.

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

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

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, percutaneous coronary intervention, diagnostic coronary angiography and arterial ultrasound services are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria for the services are met.

PERCUTANEOUS CORONARY INTERVENTION, CORONARY ANGIOGRAPHY AND ARTERIAL ULTRASOUND SERVICES FOR DIAGNOSTIC PURPOSES

Coverage determinations for the use of percutaneous coronary intervention, diagnostic coronary angiography and arterial ultrasound services for diagnostic purposes will be based on the National Coverage Determination (NCD) and/or Local Coverage Determination (LCD). If an NCD and LCD do not exist, then the Company's medical policy or the AIM Specialty Health® (AIM) Clinical Appropriateness Guidelines will apply.

PERCUTANEOUS CORONARY INTERVENTION, CORONARY ANGIOGRAPHY AND ARTERIAL ULTRASOUND SERVICES FOR SCREENING PURPOSES

Coverage determinations for the use of percutaneous coronary intervention, diagnostic coronary angiography and arterial ultrasound services for screening purposes will be based on the National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or The Guide to Medicare Preventive Services.

Description

The Company has delegated the responsibility of utilization management activities for percutaneous coronary intervention, coronary angiography and arterial ultrasound to AIM Specialty Health®AIM), with the exception of services performed on an emergent basis. To determine medical necessity for these services, AIM first utilizes Medicare guidelines (e.g., Local Coverage Determinations (LCD), National Coverage Determinations NCD). If no Medicare guidelines exist, AIM will utilize their Clinical Appropriateness Guidelines for percutaneous coronary intervention, coronary angiography and arterial ultrasound and to direct the application of these services for our members. Multiple sources were used to develop these guidelines, including technology assessments, peer-reviewed medical literature, clinical outcomes research, and consensus opinion in medical practice. The primary resources include:
  • American College of Radiology (ACR) Appropriateness Criteria
  • American Institute of Ultrasound Medicine (AIUM)
  • Society of Interventional Radiology
  • Society of Nuclear Medicine (SNM)
  • American College of Cardiology (ACC)
  • American Heart Association (AHA)
  • American Heart Association Task Force (AHATF)
  • American Society of Nuclear Cardiology (ASNC)
  • American Society of Echocardiography (ASE)
  • American College of Cardiology Foundation (ACCF)
  • Heart Failure Society of American (HFSA)
  • Heart Rhythm Society (HRS)
  • Society of Cardiovascular Anesthesiologists
  • Society for Cardiovascular Angiography and Interventions (SCAI)
  • Society of Critical Care Medicine (SCCM)
  • Society of Cardiovascular Computed Tomography (SCCT)
  • Society for Cardiovascular Magnetic Resonance (SCMR)
  • Society for Vascular Medicine
  • Society for Vascular Surgery
  • Society of Thoracic Surgeons (STS)
  • American Heart Association (AHA)
  • American Association for Thoracic Surgery (AATS)
  • Agency for Healthcare Research and Quality (AHRQ)
  • Centers for Medicare & Medicaid Services (CMS)
  • National Guideline Clearinghouse

References

American Imaging Management (AIM) Specialty Health® . Clinical Appropriateness Guidelines: Arterial Ultrasound. [AIM Web site]. 03/09/2019. Available at: http://www.aimspecialtyhealth.com/PDF/Guidelines/2019/Mar09/AIM_Guidelines_Cardiac.pdf. Accessed March 12, 2019.

American Imaging Management (AIM) Specialty Health® . Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography. [AIM Web site]. 03/09/2019. Available at: http://www.aimspecialtyhealth.com/PDF/Guidelines/2019/Mar09/AIM_Guideline_DiagnosticCoronaryAngiography.pdf. Accessed March 12, 2019.

American Imaging Management (AIM) Specialty Health® . Clinical Appropriateness Guidelines: Percutaneous Coronary Intervention. [AIM Web site]. 03/09/2019. Available at: http://www.aimspecialtyhealth.com/PDF/Guidelines/2019/Mar09/AIM_Guidelines_PCI.pdf. Accessed March 12, 2019.

Department of Health and Human Services. Center for Medicare and Medicaid Services. Medicare Preventive Services. Quick Reference Information: Preventive Services. December 2018. Available at: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html. Accessed March 12, 2019.

Novitas Solutions, Inc. Local Coverage Article.(A52992): Non-invasive cerebrovascular arterial studies. [Novitas Solutions, Inc. Web site]. 12/01/2016. Available at:
https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52992&ver=6&Date=12%2f01%2f2016&DocID=A52992&bc=hAAAABAAAAAAAA%3d%3d&. Accessed March 12, 2019.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35397: Non-invasive cerebrovascular arterial studies. [Novitas Solutions, Inc. Web site]. 10/01/2018. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35397.
Accessed March 12, 2019.



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)

See Attachment A for a list of procedure codes applicable to percutaneous coronary intervention, coronary angiography and arterial ultrasound.


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)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound
Description: Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound Code List



 Policy: MA09.002l:High-Technology Radiology Services

 Policy: MA11.011c:Artificial Hearts and Ventricular Assist Devices (VADs)

 Policy: MA11.012d:Endovascular Grafts for Abdominal Aortic Aneurysms, Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms

 Policy: MA11.013b:Percutaneous Left Atrial Appendage (LAA) Closure for Non-Valvular Atrial Fibrillation (NVAF)

 Policy: MA11.027c:Transcatheter Aortic Valve Replacement (TAVR) and Transcatheter Mitral Valve Repair (TMVR)

 Policy: MA11.040b:Transcatheter Closure of Cardiac Septal Defects

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

 Policy: MA11.060c:Catheter Ablation of Cardiac Arrhythmias

 Policy: MA11.062:Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions




Policy History

MA11.113b:
06/29/2019This version of the policy will become effective 07/01/2019.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Arterial Ultrasound . These guidelines will become effective 07/01/2019. These guidelines are available online at:http://www.aimspecialtyhealth.com/CG-Cardiology.html.
MA11.113a:
05/01/2019This version of the policy will become effective 05/01/2019.

The following HCPCS codes have been added to Attachment A of this policy:
C9600; C9601; C9602; C9603; C9604; C9605; C9607; C9608 [Medically Necessary].

MA11.113
01/02/2018This version of the policy will become effective 01/02/2018.

The following new policy has been developed to communicate the Company’s delegation of precertification/preapproval of percutaneous coronary intervention, coronary angiography, and arterial ultrasound to AIM Specialty Health® (AIM), with the exception of services performed on an emergent basis.




Version Effective Date: 07/01/2019
Version Issued Date: 07/01/2019
Version Reissued Date: N/A