Commercial

Medical Policy

Notification

Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aorto-Iliac Aneurysms, and Infrarenal Aortic Aneurysms

Notification Issue Date:

This version of the policy will become effective 12/30/2019.

The policy has been reviewed and reissued to communicate the Company’s continuing position on Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms. Clinical information updated to reiterate Experimental/Investigational position for the use of wireless endovascular pressure sensors.

Title:

Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aorto-Iliac Aneurysms, and Infrarenal Aortic Aneurysms

Policy #:

11.02.10p

Policy

MEDICALLY NECESSARY

Endovascular graft repair of nonruptured abdominal aortic aneurysms (AAA), aorto-iliac aneurysms, and infrarenal aortic aneurysms is considered medically necessary and, therefore, covered when using US Food and Drug Administration (FDA)-approved devices, based on FDA-approved specifications.

Emergency endovascular repair (eEVAR) of a ruptured abdominal aortic aneurysm with an endoprosthesis is considered medically necessary and, therefore, covered when all of the following criteria are met:

An FDA-approved device is used for the surgical procedure.
The individual must be sufficiently stable to undergo detailed computed tomography (CT) examination for anatomic measurements.
The aneurysm should be anatomically appropriate for endovascular repair.

EXPERIMENTAL/INVESTIGATIONAL

All other uses for endovascular graft repair and eEVAR are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.

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, the endovascular graft repair of abdominal aortic aneurysms (AAA), aorto-iliac aneurysms, and infrarenal aortic aneurysms is covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met. However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the US Food and Drug Administration (FDA) for the endovascular graft repair of AAAs, aorto-iliac aneurysms, and infrarenal aortic aneurysms (e.g. Endurant II/Endurant IIs Stent Graft System, INCRAFT AAA Stent Graft System, Zenith Fenestrated AAA Endovascular Graft, Aorfix AAA Flexible Stent Graft System, Alto Abdominal Stent Graft System, TREO Abdominal Stent-Graft System).

Description

An aneurysm is the abnormal bulging of a vessel, usually due to a congenital or acquired weakness or thinning of the vessel wall. A true aneurysm is a degenerative atherosclerotic process that involves all three layers of the aorta: the endothelium, the media, and the adventitia. Aneurysms are classified by shape, how they are formed, and their location along the aorta. Symptoms may or may not be present and differ with location. The majority of aneurysms are coincidentally found during clinical examination or radiographic investigations for other diseases. The incidence of aneurysms is known to increase with age, to be more common in men than in women, and to be strongly associated with cigarette smoking.

The most common type of aneurysm is an abdominal aortic aneurysm (AAA), which is an abnormal dilatation of the lower part of the aorta. Elective procedures for AAA repair and rupture prevention are usually considered when the diameter of the aneurysm is 1.5 times the diameter of the normal segment. According to the American College of Cardiology (ACC) and the American Heart Association (AHA) most recent guidelines, this measurement is 5.5 cm in diameter in men and 5.0 cm in diameter in women.

AAAs are often described based on their relation to nearby arteries. An aneurysm arising between the abdominal aorta and the common iliac artery, or that includes the abdominal aorta and the common iliac artery, is known as an aortoiliac aneurysm. An aneurysm originating distal to the renal arteries, in which there is a segment of nonaneurysmal aorta that extends inferiorly to the origins of the renal arteries, is known as an infrarenal abdominal aortic aneurysm.

The method of intervention for an aneurysm usually depends on the size, symptoms, rate of growth noted with successive diagnostic imaging tools, and whether the individual is considered healthy enough to undergo the repair procedure. One method of intervention for aneurysm repair is the use of endovascular grafts.

Endovascular grafts were developed and used as a minimally invasive, catheter-based alternative to open surgical repair because they have lower periprocedural mortality and morbidity rates. An endovascular graft is applied by inserting a catheter into the femoral artery and utilizing radiologic guidance to advance and position a guidewire for placement at the aneurysm site. The components of the endograft device are then deployed to exclude the aneurysm from the circulation and to establish normal blood flow. There must be an adequate normal aorta wall above and below the aneurysm to anchor the device and to ensure that the aneurysm is likely to be excluded from circulation. This assessment is usually made on the basis of diagnostic imaging (mainly CT scanning) and, occasionally, angiography.

Emergency endovascular repair (eEVAR) of ruptured AAAs continues to be studied as an alternative to decrease the high mortality rate associated with open surgical repair. Additional considerations, such as the possibility of aneurysm enlargement, graft migration, endoleaks, the need for possible reintervention, and paraplegia due to spinal cord ischemia during the endovascular procedure illustrate the need for further research.

Several endovascular grafts and their delivery systems have been approved by the US Food and Drug Administration (FDA) for use in the abdominal aorta, aortic-iliac bifurcation, and infrarenal aorta. Fenestrated grafts are designed with openings in the wall that are placed across the renal or celiac arteries while maintaining vessel patency. Additionally, extensions can be placed from inside the endograft into the visceral arteries to create a hemostatic seal.

Wireless sensors implanted in an aortic aneurysm sac after endovascular repair have been investigated to measure postprocedural pressure. There is no current published literature to indicate that an endosensor is a recommended part of the endovascular repair of AAA. Current published studies are lacking support for the use of wireless pressure sensors to indicate endoleaks in aneurysm repairs. Further long-term studies are needed to assess for any long-term complications. The evidence to date consists mainly of small case series, which is insufficient to permit conclusions concerning the effect of this device on health outcomes.

References

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Coding

CPT Procedure Code Number(s)

33894, 33895, 34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709, 34710, 34711, 34712, 34713, 34714, 34715, 34716, 34717, 34718, 34808, 34812, 34813, 34820, 34833, 34834, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 36140, 36200, 36245, 36246, 36247, 36248

THE FOLLOWING CODES ARE USED TO REPRESENT AN UNSUCCESSFUL ENDOVASCULAR REPAIR OF AN ABDOMINAL AORTIC ANEURYSM (AAA) THAT REQUIRED TREATMENT WITH AN URGENT OR EMERGENT OPEN PROCEDURE:

34830, 34831, 34832

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy.

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 11.02.10p:

06/10/2026	This policy has been reissued in accordance with the Company's annual review process.
05/28/2025	This policy has been reviewed and reissued to communicate the Company's continuing position on endovascular grafts for abdominal aortic aneurysms (AAA), aorto-Iliac aneurysms, and infrarenal aortic aneurysms.
09/04/2024	This policy has been reissued in accordance with the Company's annual review process.
06/28/2023	The policy has been reviewed and reissued to communicate the Company's continuing position on Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aorto-Iliac Aneurysms, and Infrarenal Aortic Aneurysms.
09/21/2022	The policy has been reviewed and reissued to communicate the Company's continuing position on Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms.
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 this policy: 33894 33895

Revisions From 11.02.10o:

03/15/2021

This version of the policy will become effective 03/15/2021.

Policy statement for implanted wireless intra-aneurysm pressure sensors has been deleted

The following CPT codes have been added to this policy:

34717

34718

The following CPT code has been removed from this policy:

37799

The following HCPCS code has been removed from this policy:

C1889

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

A52.01 Syphilitic aneurysm of aorta

I71.3 Abdominal aortic aneurysm, ruptured

I71.4 Abdominal aortic aneurysm, without rupture

I72.3 Aneurysm of iliac artery

Q25.43 Congenital aneurysm of aorta

S35.09xA Other injury of abdominal aorta, initial encounter

S35.09xD Other injury of abdominal aorta, subsequent encounter

S35.09xS Other injury of abdominal aorta, sequela

Revisions From 11.02.10n:

12/30/2019

This version of the policy will become effective 12/30/2019. The policy has been reviewed and reissued to communicate the Company's continuing position on Endovascular Grafts for Adbominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms. Clinical information updated to reiterate Experimental/Investigational position for the use of wireless endovascular pressure sensors.

Revisions From 11.02.10m:

03/26/2018

The policy has been reviewed and reissued to communicate the Company’s continuing position on Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms.

The following ICD-10 CM codes have been removed from this policy:

I71.02 Dissection of abdominal aorta
I77.811 Abdominal aortic ectasia
Q25.49 Other congenital malformations of aorta

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

Q25.43 Congenital aneurysm of aorta

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

1/1/2022

Version Issued Date:

12/31/2021

Version Reissued Date:

6/10/2026