Notification

Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound


Notification Issue Date: 10/03/2017

This 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.



Medical Policy Bulletin


Title:Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound

Policy #:11.02.27

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

This policy does not apply to those members for whom Independence Administrators serves as the claims administrator.

The intent of this policy is to communicate that the Company has delegated precertification/preapproval of percutaneous coronary intervention, coronary angiography and arterial ultrasound AIM Specialty Health (AIM). Percutaneous coronary intervention, coronary angiography and arterial ultrasound are considered not medically necessary when they are used for conditions that are not addressed in the AIM Clinical Appropriateness Guidelines.

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 the program. Refer to Attachment A of this policy for a complete list of codes that require precertification for percutaneous coronary intervention, coronary angiography and arterial ultrasound.

The Company requires precertification/preapproval of percutaneous coronary intervention, diagnostic coronary angiography and arterial ultrasound through AIM, with the exception of services performed on an emergent basis. In addition, AIM utilizes their Clinical Appropriateness Guidelines to determine the medical necessity for these services:

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 require precertification/preapproval through AIM; irrespective of the precertification/preapproval requirements for the other outpatient procedure.

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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, percutaneous coronary Intervention, coronary angiography and arterial ultrasound are covered under the medical benefits of the Company’s products when the medical necessity criteria for the services are met.

Description

The Company has delegated the responsibility for 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. AIM uses its Clinical Appropriateness Guidelines to determine medical necessity 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: Percutaneous Coronary Intervention. [AIM Web site]. 05/15/2017. Available at: http://www.aimspecialtyhealth.com/. [Proprietary]. Accessed August 11, 2017.

American Imaging Management (AIM) Specialty Health® . Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography. [AIM Web site]. 07/01/2017. Available at: http://www.aimspecialtyhealth.com/. [Proprietary]. Accessed August 11, 2017.

American Imaging Management (AIM) Specialty Health®. Clinical Appropriateness Guidelines: Arterial Ultrasound. [AIM Web site]. 10/31/2016. Available at: http://www.aimspecialtyhealth.com/PDF/Guidelines/2016/Oct31/AIM_Guidelines_ArterialUltrasound.pdf. Accessed August 11, 2017.

Department of Health and Human Services. Center for Medicare and Medicaid Services. Medicare Preventive Services. Quick Reference Information: Preventive Services. November 2016. Available at: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html. Accessed August 11, 2017.





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)

Refer to 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: 09.00.46v:High-Technology Radiology Services (Independence)

 Policy: 11.02.06l:Catheter Ablation of Cardiac Arrhythmias

 Policy: 11.02.10m:Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms

 Policy: 11.02.11g:Transcatheter Closure of Cardiac Septal Defects

 Policy: 11.02.12i:Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting of the Extracranial Carotid Artery or Intracranial Artery

 Policy: 11.02.16r:Ventricular Assist Devices (VADs)

 Policy: 11.02.17f:Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions

 Policy: 11.02.25f:Transcatheter Cardiac Valve Procedures

 Policy: 11.02.26a:Percutaneous Left Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 01/02/2018
Version Issued Date: 01/02/2018
Version Reissued Date: N/A

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