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Endovascular Stent Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions
11.02.17j

Policy

MEDICALLY NECESSARY

​Endovascular stent graft repair is considered medically necessary and, therefore, covered for the treatment of descending thoracic aortic aneurysm, when using US Food and Drug Administration (FDA)–approved devices, based on approved specifications.

Endovascular stent graft repair is considered ​medically necessary and, therefore, covered for the treatment of diagnosed nonaneurysmal lesions of the descending thoracic aorta, when using FDA-approved devices, based on approved specifications.

Endovascular​ stent graft repair is considered medically necessary and, therefore, covered for the treatment of rupture of the descending thoracic aorta.

EXPERIMENTAL/INVESTIGATIONAL

All other indications for endovascular stent graft repair are considered experimental/investigational, and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.

ENDOVASCULAR STENT GRAFT REPAIR USING A THORACIC BRANCHED ENDOGRAFT 
Endovascular stent graft repair of lesions of the descending thoracic aorta using a thoracic branch endoprosthesis (i.e., Gore TAG thoracic branch endoprosthesis [TBE device]) is considered experimental/investigational, and, therefore, not covered because the safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.
​​
​​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, endovascular stent graft repair of thoracic aortic aneurysms and nonaneurysmal lesions are covered under the medical benefits of the Company's products when the medical necessity criteria in this policy are met.

Subject to the terms and conditions of the applicable benefit contract, endovascular stent graft repair for rupture of the descending thoracic aorta is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for the treatment of descending thoracic aortic aneurysms and nonaneurysmal lesions.​

Description

THORACIC ANEURYSM

An aortic aneurysm is an abnormal swelling, or dilation, in the wall of the aorta, the body's largest artery. A thoracic aortic aneurysm occurs in an area of the aorta that passes through the chest, and it can occur anywhere along the aorta above the diaphragm, including the ascending aorta, the aortic arch, and the descending thoracic aorta. Left untreated, an aortic aneurysm can enlarge over time, increasing the risk of dissection. The most common cause of a thoracic aortic aneurysm is hardening of the arteries. Thoracic aneurysms are also associated with individuals who have high cholesterol and long-term high blood pressure, as well as individuals who have congenital connective tissue disorders (i.e., Marfan syndrome).

The traditional standard of treatment for a thoracic aortic aneurysm is open surgical repair, which involves resection of the aneurysm and graft implantation of the diseased segment. This surgical procedure entails a long operative duration that includes lateral thoracotomy and cardiopulmonary bypass. Complications may include spinal cord ischemia, myocardial infarction, pulmonary dysfunction, renal failure, and bowel ischemia or infarction. Abdominal aortic aneurysms have been successfully treated with endovascular stent grafts, which generated an interest in applying endovascular stent grafts to thoracic aortic aneurysms.

Thoracic endovascular aneurysm repair (TEVAR) has been investigated as an alternative to the open surgical procedure for repairing a thoracic aortic aneurysm, and can also be used as prophylactic treatment of an aneurysm at significant risk of future rupture or dissection. TEVAR involves the percutaneous (through the skin) placement of a stent graft in the descending thoracic or thoracoabdominal aorta to reduce mortality from aneurysm rupture. Indications for elective surgical repair of aortic aneurysm are based on the estimated prognosis of the untreated aneurysm weighed against the morbidity and mortality of the intervention. The prognosis of thoracic aortic aneurysms is based on the risk of rupture according to the size and location of the aneurysm (i.e., the ascending or descending or thoracoabdominal aorta).

Several grafts have been approved by the US Food and Drug Administration (FDA) for the treatment of descending thoracic aortic aneurysms, including the Gore®​​ TAG® Thoracic Endoprosthesis (W.L. Gore and Associates, Inc., Flagstaff, AZ), the Zenith TX2® Thoracic TAA Endovascular Graft (Cook Incorporated, Bloomington, IN), the Talent™ Thoracic Stent Graft System (Medtronic Vascular, Santa Rosa, CA), the Valiant™ Thoracic Stent Graft (Medtronic Vascular, Santa Rosa, CA), and the Relay® Thoracic Stent Graft (Bolton Medical, Sunrise, FL).

According to the Society of Thoracic Surgeons, TEVAR is performed as follows: during endovascular surgery, a synthetic graft (stent graft consisting of a polyester tube inside a metal cylinder) is attached to the end of a thin tube (catheter), which is inserted into the bloodstream, usually through the femoral artery in the groin. The surgeon threads the stent graft to the part of the aorta where the aneurysm is located by watching the progression of the catheter on an X-ray monitor. Once the graft is in place over the aneurysm, the graft is expanded. The stent graft reinforces the weakened section of the aorta to prevent the aneurysm from rupturing. The metal cylinder framing the stent graft is expanded to hold tightly against the wall of the aorta, thus diminishing the blood supply to the aneurysm. Ultimately, the blood flows through the stent graft, bypassing the aneurysm. Over time, the aneurysm should shrink.

​THORACIC DISSECTION

A thoracic dissection involves an intimal tear that permits blood to enter the potential space between the intima and the muscular wall of the thoracic aorta. This leakage of blood between the layers of the vessel wall can result in rupture of the aorta. Rupture of the aorta can lead to serious consequences, including death.

Aortic dissections can be subdivided into two categories: type A and type B. Type A involves the aortic arch or the ascending part of the aorta and is usually treated surgically. Type B is confined to the descending aorta and can be treated medically when there are no serious complications (i.e., shock or visceral ischemia), which would require surgical intervention. Type B dissection can be further categorized as complicated and uncomplicated dissection. For uncomplicated descending (type B) aortic dissection, the evidence does not support TEVAR for treatment. Medical therapy is still superior for this condition. A complicated acute type B aortic dissection can have either of the following clinical presentations: 1) a rupture of the descending aorta into the free pleural space, or 2) malperfusion, which results from the dissection compromising the blood flow, creating a false lumen pressurization and obliteration of the true lumen, so that branch artery flow is threatened, which can cause ischemic complications.

In January 2014, the FDA expanded the indication for the Valiant thoracic stent graft with the Captivia delivery system to include all lesions of the descending thoracic aorta, including type B dissections. The expanded approval was based on the Medtronic Dissection Trial (NCT01114724), a prospective, nonrandomized study that evaluated the performance of the Valiant stent graft for acute, complicated type B dissection, which included 50 individuals enrolled at 16 sites.

THORACIC AORTIC RUPTURE

Rupture of the thoracic aorta is a life-threatening emergency that is nearly always fatal if untreated. Thoracic artery rupture can result from a number of factors. Aneurysms can rupture due to progressive dilatation and pressure of the aortic wall. Rupture can also occur as a result of traumatic injury to the aorta, such as occurs with blunt chest trauma. Penetrating injuries that involve the aorta can also lead to rupture. Penetrating ulcers can occur in the setting of widespread atherosclerotic disease and lead to aortic rupture.

Emergent repair of thoracic artery rupture is indicated in many cases in which there is free bleeding into the mediastinum and/or complete transection of the aortic wall. In some cases of aortic rupture, where the aortic media and adventitia are intact, watchful waiting with delayed surgical intervention can be performed. With the advent of TEVAR, the decision making for intervention may be altered, as there may be a greater tendency to intervene on borderline cases due to the potential for less adverse events with TEVAR.

For traumatic thoracic aortic injury and aortic rupture, nonrandomized comparative data suggest a benefit for TEVAR in reducing periprocedural morbidity and mortality. The FDA granted approval for endovascular treatment of thoracic aortic ruptures in 2012, and specialty society recommendations include endovascular stent grafts as a treatment option for acute thoracic aortic rupture. In addition, it is expected that random controlled trials will be difficult to perform for this indication due to the emergent nature.
 
ENDOVASCULAR STENT GRAFT REPAIR USING A THORACIC BRANCHED ENDOGRAFT ​

Thoracic endovascular aortic repair has emerged as a treatment for individuals with descending thoracic aortic aneurysms. ​For aneurysms involving the aortic arch in the region of the left subclavian artery (LSA), branch vessel preservation to maintain blood flow to the LSA is recommended. Branched thoracic ​​endografts have been proposed as an alternative to surgical revascularization of the LSA. 

The Gore TAG thoracic branch endoprosthesis (TBE) device​ received FDA approval through the premarket approval process on May 13, 2022. This device is indicated for endovascular repair of lesions of the descending thoracic aorta, while maintaining flow into the LSA, in individuals who are at high risk for debranching subclavian procedures. ​The device incorporates a single internal retrograde branch for arch vessel perfusion.  

Liang et al. reported 3-year midterm outcomes of endovascular repair of aortic arch aneurysms with the Gore TAG TBE. The first study arm enrolled individuals with an intact descending thoracic aortic aneurysm extending to the distal arch with LSA incorporation (zone 2). The second arm enrolled individuals with arch aneurysms requiring incorporation of the left carotid or innominate artery (zone 0/1) and extra-anatomic surgical revascularization of the remaining aortic arch vessels. The cohort consisted of 40 individuals (31 zone 2 and nine in zone 0/1). The majority were male (52%). During 3-year follow up, there was no device migration, fracture, or aortic rupture in either arm. In the zone 2 arm, freedom from reintervention was 97% at 1 and 3 years but there were two-side branch occlusions. Two individuals had aneurysm enlargement greater than 5 mm without documented endoleak or reintervention. Freedom from death at 1 and 3 years was 90% and 84%. In the zone 0/1 arm there were no reinterventions, loss of branch patency, or aneurysm enlargement at 3 years. Cerebrovascular events occurred in three individuals during follow up: two unrelated to the device or procedure, and one of unknown relationship. Two individuals in this arm died during the follow-up period, both unrelated to the procedure or the aneurysm.​ Initial 3-year results of the TBE device for endovascular repair of arch aneurysms show favorable patency and durability with low rates of graft-related complications​. The primary limitation of this study is the small sample size due to the feasibility nature of this study. 

Dake et al. (2022) reported early outcomes from the US​ pivotal trial for the Gore TAG TBE device. This nonrandomized, prospective study of a single branched aortic endograft involved 34 investigative sites and reported the 1-year results of 84 individuals who underwent treatment of descending thoracic aneurysms with graft deployment in zone 2 and a side branch into the LSA. More than one half of the individuals were male (63%). Their average age was 70 ± 11 years. The aneurysm morphology was fusiform in 43 and saccular in 41 individuals. The mean aneurysm diameter at screening was 56.2 mm. The mean follow-up was 30 months (range, 2.6–50.7 months). Predefined technical success with implantation of the device in landing zone 2 was achieved in 92% of individuals (n = 77). There were no cases of aortic rupture, lesion-related mortality, or new-onset renal failure. There was no perioperative (30-day) mortality. A single case each of permanent paraplegia and paraparesis occurred. Three individuals experienced a procedure-related stroke. Through 12 months, four individuals died; none of the deaths were adjudicated as related to the device or procedure. One aortic reintervention was required. A single case of aortic enlargement (core laboratory) was reported at 6 months. Type I (n= 3) and III (n= 5) endoleaks occurred in 9.8% of individuals, of which one (type III) required reintervention. Results of this study demonstrate that early safety and efficacy outcomes are maintained up to 12 months after the endovascular procedure with low mortality and reintervention rates and an acceptable frequency of procedural complications, including neurologic complications. Study interpretation is limited by small sample size.​

In 2025, Wang et al. analyzed data from the Dake et al. (2022) pivotal trial, focused on stroke risk. A total of 238 individuals were in the trial. There were 84 individuals with aneurysm, 132 with dissection, nine with trauma, and 13 with other isolated lesions. There were baseline characteristics that differed significantly between these groups. Six strokes, according to the World Health Organization definition, occurred within 30 days of a Gore TAG TBE implantation, and eight strokes occurred from 30 days to 12 months postimplantation. Half of all the strokes were considered disabling.


Desai et al. (2025) analyzed the dissection cohort of the Dake et al. (2022) pivotal trial. A total of 132 individuals were in the study: 25 with acute type B dissections, 79 with chronic type B dissections, and 28 with residual dissections after an open type A repair. Six individuals died and two strokes occurred within 30 days of the procedure. 


SUMMARY

Multiple studies suggest that, compared to open surgery, elective repair of descending thoracic aortic aneurysms with endovascular stent grafts for the treatment of a thoracic aortic aneurysm is associated with lower short-term mortality and lower complication rates.

The published studies of complicated acute type B dissections suggest increased survival for individuals treated with TEVAR, especially those who are not candidates for open surgical repair.

The available, albeit limited, evidence suggests that early mortality and complications are less with endovascular stent graft treatment of thoracic artery ruptures compared with open surgery.


Branched thoracic endovascular stent graft repair has been proposed as an alternative to surgical revascularization of the LSA, but the technology has limited safety, efficacy, and durability evidence. Long-term safety and efficacy research is necessary and appears to be ongoing at the request of the FDA (Centers for Devices and Radiological Health).​ Prospective, randomized comparisons of these techniques are warranted. ​

References

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Nienaber CA, Kische S, Rousseau H, et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv. 2013;6(4):407-416.

Nienaber CA, Zannetti S, Barbieri B, et al. INvestigation of STEnt grafts in patients with type B Aortic Dissection: design of the INSTEAD trial--a prospective, multicenter, European randomized trial. Am Heart J. 2005;149(4):592-599.

Orandi BJ, Dimick JB, Deeb GM, et al. A population-based analysis of endovascular versus open thoracic aortic aneurysm repair. J Vasc Surg. 2009;49(5):1112-1116.

Pang D, Hildebrand D, Bachoo P. Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury. Cochrane Database Syst Rev. 2015;9:CD006642.

Piffaretti G, Benedetto F, Menegolo M, et al. Outcomes of endovascular repair for blunt thoracic aortic injury. J Vasc Surg. 2013;58(6):1483-1489.

Ramdass M. TEVAR for symptomatic stanford B dissection: a systematic review of 30-Day Mortality and Morbidity. Thorac Cardiovasc Surg. 2015;63(2):97-112.

Rectenwald JE, Huber TS, Martin TD, et al. Functional outcome after thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2002;35(4):640-647.

Roselli EE, Idrees J, Greenberg RK, et al. Endovascular stent grafting for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg. 2015;149(1):144-151.

Ruan ZB, Zhu L, Chen GC, et al. Early and long-term effect of thoracic endovascular aortic repair for stanford B aortic dissection. Thorac Cardiovasc Surg. 2015;63(2):120-125.

Safi HJ, Miller CC 3rd, Subramaniam MH, et al. Thoracic and thoracoabdominal aortic aneurysm repair using cardiopulmonary bypass, profound hypothermia, and circulatory arrest via left side of the chest incision. J Vasc Surg. 1998;28(4):591-598.

Safi HJ, Subramaniam MH, Miller CC, et al. Progress in the management of type I thoracoabdominal and descending thoracic aortic aneurysms. Ann Vasc Surg. 1999;13(5):457-462.

 

Scalea TM, Feliciano DV, DuBose JJ, et al. Blunt thoracic aortic injury: endovascular repair is now the standard. J Am Coll Surg. 2019;228(4):605-610. 

Sood V, Patel HJ, Williams DM, et al. Open and endovascular repair of the nontraumatic isolated aortic arch aneurysm. J Vasc Surg. 2014;60(1):57-63.

Steuer J, Eriksson MO, Nyman R, et al. Early and long-term outcome after thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissection. Eur J Vasc Endovasc Surg. 2011;41(3):318-323.

Stone DH, Brewster DC, Kwolek CJ, et al. Stent-graft versus open-surgical repair of the thoracic aorta: mid-term results. J Vasc Surg. 2006;44(6):1188-1197.

Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008;85(1 suppl):S1-41.


Sweet MP, Azizzadeh A, Oderich GS, et al. Early outcomes of endovascular repair of aortic arch lesions in zone 0/1 with a thoracic branched endoprosthesis. J Vasc Surg. 2025;82(5):1591-1600.e4.

Taylor PR, Gaines PA, McGuinness CL, et al. Thoracic aortic stent grafts--early experience from two centres using commercially available devices. Eur J Vasc Endovasc Surg. 2001;22(1):70-76.

Thompson CS, Gaxotte VD, Rodriguez JA, et al. Endoluminal stent grafting of the thoracic aorta: initial experience with the Gore Excluder. J Vasc Surg. 2002;35(6):1163-1170.

Thrumurthy SG, Karthikesalingam A, Patterson BO, et al. A systematic review of mid-term outcomes of thoracic endovascular repair (TEVAR) of chronic type B aortic dissection. Eur J Vasc Endovasc Surg. 2011;42(5):632-647.

 

Ultee KHJ, Zettervall SL, Soden PA, et al. The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms. J Vasc Surg. 2017;66(2):343-52 e341.

Umaña JP, Miller DC, Mitchell RS. What is the best treatment for patients with acute type B aortic dissections—medical, surgical, or endovascular stent-grafting? Ann Thorac Surg. 2002;74(5):S1840-3.


Upchurch GR Jr, Escobar GA, Azizzadeh A, et al. Society for Vascular Surgery clinical practice guidelines of thoracic endovascular aortic repair for descending thoracic aortic aneurysms. J Vasc Surg. 2021;73(1S):55S-83S.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. GORE TAG Thoracic Endoprosthesis. Premarket approval letter. [FDA Web site]. 03/23/05. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf4/P040043A.pdf. Accessed March 30, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. GORE TAG Thoracic Endoprosthesis. Premarket approval supplement letter. [FDA Web site]. 01/13/2012. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf4/p040043s040a.pdf. Accessed March 30, 2026.

US Food and Drug Administration (FDA). Summary of Safety and Effectiveness. GORE TAG Thoracic Endoprosthesis. 9/10/2013. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf4/p040043s051b.pdf. Accessed March 30, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Relay Thoracic Stent-Graft with Plus Delivery System. Premarket approval letter. [FDA Web site]. 09/21/2012. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf11/p110038a.pdf. Accessed March 30, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. TalentTM Thoracic Stent Graft System. Premarket approval letter. [FDA Web site]. 06/05/2008. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf7/p070007a.pdf. Accessed March 30, 2026. 

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Valiant Thoracic Stent Graft with the Captivia Delivery System. Premarket approval letter. [FDA Web site]. 04/13/2011. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf10/p100040a.pdf. Accessed March 30, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Valiant Thoracic Stent Graft with the Captivia Delivery System. Premarket approval letter. [FDA Web site]. 1/22/2014. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf10/P100040S012a.pdf. Accessed March 30, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Zenith® TX2® Thoracic TAA Endovascular Graft with the H&LB One-Shot™ Introduction System. Premarket approval letter. [FDA Web site]. 05/21/08. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf7/p070016a.pdf. Accessed March 30, 2026.

US Food and Drug Administration (FDA). Summary of Safety and Effectiveness. Valiant Thoracic Stent Graft with the Captivia Delivery System. 10/26/2012. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf10/p100040s008b.pdf. Accessed March 30, 2026.

US Food and Drug Administration (FDA). Summary of Safety and Effectiveness. Valiant Thoracic Stent Graft with the Captivia Delivery System. 01/22/2014. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf10/p100040s012b.pdf. Accessed March 30, 2026.


US Food and Drug Administration (FDA). Center for Devices and Radiological Health. GORE TAG Thoracic Branch Endoprosthesis (TBE Device). Premarket approval letter. [FDA Web site]. 05/13/2022. Available at: P210032 (fda.gov). Accessed March 30, 2026.​

Vallabhajosyula P, Gottret JP, Bavaria JE, et al. Endovascular repair of the ascending aorta in patients at high risk for open repair. J Thorac Cardiovasc Surg. 2015;149(2 Suppl):S144-50.

van Bogerijen GH, Patel HJ, Williams DM, et al. Propensity adjusted analysis of open and endovascular thoracic aortic repair for chronic type B dissection: a twenty-year evaluation. Ann Thorac Surg. 2015;99(4):1260-1266.

van Dongen EP, Schepens MA, Morshuis WJ, et al. Thoracic and thoracoabdominal aortic aneurysm repair: use of evoked potential monitoring in 118 patients. J Vasc Surg. 2001;34(6):1035-1040.

Virtue Registry Investigators. Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE Registry. Eur J Vasc Endovasc Surg. 2014;48(4):363-371.


Wang GJ, Desai ND, Bavaria JE, et al. Characterization of strokes following Gore thoracic branch endografting requiring zone 2 landing. Ann Vasc Surg. 2025;110(A):447-459.


Webb TH, Williams GM. Thoracoabdominal aneurysm repair. Cardiovasc Surg.1999;7(6):573-585.

Wheatley GH 3rd, Gurbuz AT, Rodriguez-Lopez JA, et al. Midterm outcome in 158 consecutive Gore TAG thoracic endoprostheses: single center experience. Ann Thorac Surg. 2006;81(5):1570-1577.

White RA, Donayre CE, Walot I, et al. Endovascular exclusion of descending thoracic aortic aneurysms and chronic dissections: Initial clinical results with the AneuRx device. J Vasc Surg. 2001;33(5):927-934.

White RA, Miller DC, Criado FJ, et al. Report on the results of thoracic endovascular aortic repair for acute, complicated, type B aortic dissection at 30 days and 1 year from a multidisciplinary subcommittee of the Society for Vascular Surgery Outcomes Committee. J Vasc Surg. 2011;53(4):1082-1090.

Wiedemann D, Mahr S, Vadehra A et al. Thoracic endovascular aortic repair in 300 patients: long-term results. Ann Thorac Surg. 2013;95(5):1577-1583.

 

Yamaguchi T, Nakai M, Sumita Y, et al. Editor's Choice - Endovascular repair versus surgical repair for Japanese patients with ruptured thoracic and abdominal aortic aneurysms: a nationwide study. Eur J Vasc Endovasc Surg. 2019;57(6):779-786.

Zeeshan A, Woo EY, Bavaria JE, et al. Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy. J Thorac Cardiovasc Surg. 2010; 140(6 Suppl):S109-15; discussion S142-6.

Zhang H, Wang ZW, Zhou, Z et al. Endovascular stent-graft placement or open surgery for the treatment of acute type B aortic dissection: a meta-analysis. Ann Vasc Surg. 2012;26(4):454-461.​​

Coding

CPT Procedure Code Number(s)
MEDICALLY NECESSARY

33880, 33881, 33883, 33894, 33895​, 35602

EXPERIMENTAL/INVESTIGATIONAL

33882
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)

A52.01 Syphilitic aneurysm of aorta

I71.012 Dissection of descending thoracic aorta

I71.03 Dissection of thoracoabdominal aorta

I71.13 Aneurysm of the descending thoracic aorta, ruptured

I71.23 Aneurysm of the descending thoracic aorta, without rupture

I71.50 Thoracoabdominal aortic aneurysm, ruptured, unspecified

I71.60 Thoracoabdominal aortic aneurysm, without rupture, unspecified

Q25.43 Congenital aneurysm of aorta

S25.00XA Unspecified injury of thoracic aorta, initial encounter

S25.00XD Unspecified injury of thoracic aorta, subsequent encounter

S25.00XS Unspecified injury of thoracic aorta, sequela

S25.01XA Minor laceration of thoracic aorta, initial encounter

S25.01XD Minor laceration of thoracic aorta, subsequent encounter

S25.01XS Minor laceration of thoracic aorta, sequela

S25.02XA Major laceration of thoracic aorta, initial encounter

S25.02XD Major laceration of thoracic aorta, subsequent encounter

S25.02XS Major laceration of thoracic aorta, sequel

S25.09XA Other specified injury of thoracic aorta, initial encounter

S25.09XD Other specified injury of thoracic aorta, subsequent encounter

S25.09XS Other specified injury of thoracic aorta, sequela

HCPCS Level II Code Number(s)

N/A​

Revenue Code Number(s)
N/A


​

Coding and Billing Requirements

Policy History

Revisions From 11.02.17j:​
​06/10/2026
​This policy has been reviewed and reissued to communicate the Company’s continuing position on endovascular stent-graft repair of thoracic aortic aneurysms and nonaneurysmal lesions.​​​​
01/01/2026
​​This policy has been identified and updated for the HCPCS/CPT code update effective 01/01/2026.​

The following CPT code narratives have been revised:
33880, 33881, 33883

The following CPT codes have been added:
33882, 35602

The following CPT codes have been termed​:
33884, 33889, 33891​

Revisions From 11.02.17i:​
​07/09/2025
​This policy has been reviewed and reissued to communicate the Company's continuing position on Endovascular Stent Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions​.
01/01/2025
​This version of the policy will become effective 01/01/2025.

The intent of this policy has not changed; however, the following criterion has been added for endovascular stent graft repair using a thoracic branch endoprosthesis​ (i.e., Gore TAG Thoracic Branch Endoprosthesis [TBE device])​ as experimental/investigational. 

In addition, the following CPT code has been added to this policy as Experimental/Investigational:


THE FOLLOWING CODE REPRESENTS THE ENDOVASCULAR STENT GRAFT REPAIR OF LESIONS OF THE DESCENDING AORTA USING A THORACIC BRANCH ENDOPROTHESIS (I.E., GORE TAG THORACIC BRANCH ENDOPROSTHESIS [TBE DEVICE])
  • ​33999 ​

The following CPT codes have been removed from this policy:

  • ​75956, 75957, 75958

Revisions From 11.02.17h:​
​09/20/2023

​This policy has bee​​n reissued in accordance with the Company's annual review process.​
10/01/2022

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

 

This policy has been identified for the ICD-10 code update, effective 10/01/2022.


The following ICD-10 codes have been termed and removed from this policy:​ 


I71.01 Dissection of thoracic aorta

I71.1 Thoracic aortic aneurysm, ruptured

I71.2 Thoracic aortic aneurysm, without rupture​​

I71.5 Thoracoabdominal aortic aneurysm, ruptured

I71.6 Thoracoabdominal aortic aneurysm, without rupture


The following ICD-10 codes have been added to this policy:


I71.012 Dissection of descending thoracic aorta

I71.13 Aneurysm of the descending thoracic aorta, ruptured

I71.23 Aneurysm of the descending thoracic aorta, without rupture      

I71.50 Thoracoabdominal aortic aneurysm, ruptured, unspecified

I71.60 Thoracoabdominal aortic aneurysm, without rupture, unspecified


Revisions From 11.02.17g:
​08/24/2022

​The policy has been reviewed and reissued to communicate the Company’s continuing position on Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions.​
01/01/2022

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

 

This policy has been identified for the CPT code update, effective 01/01/2022.


The following CPT codes have been added to the policy:​ 33894 and 33895.


Revisions From 11.02.17f:
​11/03/2021
​This policy has bee​​n reissued in accordance with the Company's annual review process.
​11/18/2020

​The policy has been reviewed and reissued to communicate the Company’s continuing position on Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions.
12/18/2019This policy has been reissued in accordance with the Company's annual review process.
03/26/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Endovascular Stent-Graft Repair of Thoracic Aortic Aneurysms and Nonaneurysmal Lesions.

The following ICD-10 CM codes have been removed from this policy:
    I71.00 Dissection of unspecified site of aorta
    I71.8 Aortic aneurysm of unspecified site, ruptured
    I71.9 Aortic aneurysm of unspecified site, without rupture
    I79.0 Aneurysm of aorta in diseases classified elsewhere

The following ICD-10 CM codes have been added to this policy:

    Q25.43 Congenital aneurysm of aorta
    S25.00XA Unspecified injury of thoracic aorta, initial encounter
    S25.00XD Unspecified injury of thoracic aorta, subsequent encounter
    S25.00XS Unspecified injury of thoracic aorta, sequela
    S25.01XA Minor laceration of thoracic aorta, initial encounter
    S25.01XD Minor laceration of thoracic aorta, subsequent encounter
    S25.01XS Minor laceration of thoracic aorta, sequela
    S25.09XA Other specified injury of thoracic aorta, initial encounter
    S25.09XD Other specified injury of thoracic aorta, subsequent encounter
    S25.09XS Other specified injury of thoracic aorta, sequela

Effective 10/05/2017 this policy has been updated to the new policy template format.
1/1/2026
1/2/2026
6/10/2026
11.02.17
Medical Policy Bulletin
Commercial
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