Medicare Advantage

Medical Policy

Notification

Percutaneous Coronary Intervention, Coronary Angiography, and Arterial Ultrasound

Notification Issue Date:

This version of the policy will become effective on 03/14/2021.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Diagnostic Coronary Angiography . These guidelines will become effective 03/14/2021. Upon approval, these guidelines are available online http://www.aimspecialtyhealth.com/CG-Cardiology.html.

The summary changes are as follows:

Diagnostic Coronary Angiography

Added criteria to specify appropriate scenarios in individuals with suspected congenital coronary artery anomalies.

Title:

Percutaneous Coronary Intervention, Coronary Angiography, and Arterial Ultrasound

Policy #:

MA11.113o

Policy

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 Carelon Medical Benefits Management.

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 Centers for Medicare & Medicaid Services (CMS) guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no there is no Medicare coverage determination, the Company uses Carelon Medical Benefits Management 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 Carelon Medical Benefits Management Clinical Appropriateness Guidelines, they are considered not medically necessary.

Please refer to the References section of this policy for a link to the entire Carelon Medical Benefits Management Clinical Appropriateness Guidelines for percutaneous coronary intervention, diagnostic coronary angiography, and arterial ultrasound that are part of this program. Note: arterial ultrasound is addressed in the Carelon Medical Benefits Management Advanced Imaging Clinical Appropriateness Guidelines for Vascular Ultrasound and Physiologic Testing, which can be found under Carelon Medical Benefits Management Radiology Guidelines. 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 percutaneous coronary intervention, diagnostic coronary angiography, and arterial ultrasound to Carelon Medical Benefits Management. To determine medical necessity for these services, Carelon Medical Benefits Management first utilizes Medicare guidelines based on applicable statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents. If no Medicare guidelines exist, Carelon Medical Benefits Management 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 Carelon Medical Benefits Management, 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.

Carelon Medical Benefits Management does not manage percutaneous transluminal coronary lithotripsy or percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon for the Company; please refer to Company medical policy #MA00.005 Experimental/Investigational Services.

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 Carelon Medical Benefits Management 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 noninvasive 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

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 Carelon Medical Benefits Management 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 NCD, 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 Carelon Medical Benefits Management, with the exception of services performed on an emergent basis. To determine medical necessity for these services, Carelon Medical Benefits Management first utilizes Medicare guidelines based on applicable statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents. If no Medicare guidelines exist, Carelon Medical Benefits Management 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 America (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 Association for Thoracic Surgery (AATS)
Agency for Healthcare Research and Quality (AHRQ)
Centers for Medicare & Medicaid Services (CMS)
National Guideline Clearinghouse

References

Carelon Medical Benefits Management. Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography. [Carelon Web site]. 09/19/2026. Available at: Current Cardiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). [Proprietary]. Accessed September 19, 2026.

Carelon Medical Benefits Management. Clinical Appropriateness Guidelines: Percutaneous Coronary Intervention. [Carelon Web site]. 09/19/2026. Available at: Current Cardiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). [Proprietary]. Accessed September 19, 2026.

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Vascular Ultrasound and Physiologic Testing. [Carelon Web site]. 09/19/2026. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). [Proprietary]. Accessed September 19, 2026.

Department of Health and Human Services. Center for Medicare and Medicaid Services. Medicare Preventive Services. Quick Reference Information: Preventive Services. April 2024. Available at: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html. Accessed June 2, 2026.

Novitas Solutions, Inc. Local Coverage Article. (A52992): Non-invasive cerebrovascular arterial studies. [Novitas Solutions, Inc. Web site]. 01/01/2025. Available at: Article - Billing and Coding: Non-Invasive Cerebrovascular Arterial Studies (A52992). Accessed June 2, 2026.

Novitas Solutions, Inc. Local Coverage Article. (A60315). Non-invasive Arterial Duplex Ultrasound of the Upper and Lower Extremities. [Novitas Solutions, Inc. Web site] 05/17/2026. Available at: Article - Billing and Coding: Non-Invasive Arterial Duplex Ultrasound of the Upper and Lower Extremities (A60315). Accessed June 2, 2026.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35397: Non-invasive cerebrovascular arterial studies. [Novitas Solutions, Inc. Web site]. 10/17/2019. Available at: https://www .cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35397. Accessed June 2, 2026.

Notivas Solutions, Inc. Local Coverage Determination (LCD). L40276. Non-invasive Arterial Duplex Ultrasound of the Upper and Lower Extremities. [Novitas Solutions, Inc. Web site]. 05/17/2026. Available at: LCD - Non-invasive Arterial Duplex Ultrasound of the Upper and Lower Extremities (L40276). Accessed June 2, 2026.

Coding

CPT Procedure Code Number(s)

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

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

See Attachment A.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA11.113o:

09/19/2026

This version of the policy will become effective on 09/19/2026.

Carelon Medical Benefits Management has revised their Diagnostic Coronary Angiography, Percutaneous Coronary Interventions, and Vascular Ultrasound and Physiologic Testing guidelines. For a detailed summary of changes, see the specific guidelines that will become effective 09/19/2026. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiovascular-guidelines/.

Revisions From MA11.113n:

05/13/2026	This policy has been reviewed and reissued to communicate the Company's continuing position on percutaneous coronary intervention, coronary angiography, and arterial ultrasound.
04/01/2026	This version of the policy will be issued on 04/06/2026 with a retroactive effective date of 04/01/2026. Carelon Medical Benefits Management has revised their Diagnostic Coronary Angiography Guideline. For a detailed summary of changes, see the specific guidelines which will become effective 04/01/2026. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiovascular-guidelines/. The following CPT codes have been added to Attachment A of this policy: C7568, C7569, C7570

05/13/2026

This policy has been reviewed and reissued to communicate the Company's continuing position on percutaneous coronary intervention, coronary angiography, and arterial ultrasound.

04/01/2026

This version of the policy will be issued on 04/06/2026 with a retroactive effective date of 04/01/2026.

Carelon Medical Benefits Management has revised their Diagnostic Coronary Angiography Guideline. For a detailed summary of changes, see the specific guidelines which will become effective 04/01/2026. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiovascular-guidelines/.

The following CPT codes have been added to Attachment A of this policy:

C7568, C7569, C7570

Revisions From MA11.113m:

01/01/2026

This policy has been identified for the CPT code update, effective 01/01/2026.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following CPT codes have been terminated and removed from Attachment A of this policy:
92921, 92925, 92929, 92934, 92938, 92944

The following CPT codes have been added to Attachment A of this this policy:
92930, 92945

The following CPT codes have been revised in Attachment A of this this policy:
92920, 92924, 92928, 92933, 92937, 92943

Revisions From MA11.113l:

11/15/2025

This version of the policy will become effective on 11/15/2025.

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines Cardiology. For a detailed summary of changes, see the specific guidelines that will become effective 11/15/2025. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiovascular-guidelines/.

Revisions From MA11.113k:

03/24/2025

This version of the policy will become effective on 03/24/2025.

The intent of this policy has not changed; however, a statement was added to refer to Company medical policy #MA00.005 Experimental/Investigational Services for percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon.

Revisions From MA11.113j:

01/01/2025

This policy has been identified for the CPT and HCPCS code update, effective 01/01/2025.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following HCPCS code has been termed and removed from Attachment A of this policy:
C7558

The following HCPCS codes have been added to Attachment A of this this policy:
C7562, C7563
_______________________________

Addendum: On 01/14/2025, the following HCPCS code was removed from Attachment A of this policy because it was initially added in error:

C7563 Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, initial artery and all additional arteries

Revisions From MA11.113i:

10/20/2024

This version of the policy will become effective on 10/20/2024.

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines Cardiology. For a detailed summary of changes, see the specific guidelines that will become effective on 10/20/2024. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiology-guidelines/.

Please refer to Company medical policy #MA00.005 Experimental/Investigational Services for percutaneous transluminal coronary lithotripsy.

Revisions From MA11.113h:

01/02/2024

This policy has been identified for the HCPCS code update, effective 01/02/2024.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following HCPCS codes have been added to Attachment A of this this policy:
C7557, C7558

Revisions From MA11.113g:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
06/28/2023	The policy has been reviewed and reissued to communicate the Company's continuing position on Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound. The intent of the policy has not changed; however, AIM Specialty Health® has been revised to Carelon Medical Benefits Management.
01/01/2023	This policy has been identified for the CPT and HCPCS code update, effective 01/01/2023. Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. The following CPT code has been revised in Attachment A of this policy: 93568 The following HCPCS codes have been added to Attachment A of this this policy: C7516, C7517, C7518, C7519, C7520, C7521, C7522, C7523, C7524, C7525, C7526, C7527, C7528, C7529, C7533, C7552, C7553

Revisions From MA11.113f:

11/06/2022

This version of the policy will be issued on 12/05/2022 with a retro-effective date of 11/06/2022.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Diagnostic Coronary Angiography . These guidelines will become effective 11/06/2022. Upon approval, these guidelines are available online at http://www.aimspecialtyhealth.com/CG-Cardiology.html.

Revisions From MA11.113e:

03/13/2022

This version of the policy will become effective on 03/13/2022.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Diagnostic Coronary Angiography . These guidelines will become effective 03/13/2022. Upon approval, these guidelines are available online http://www.aimspecialtyhealth.com/CG-Cardiology.html.

Revisions From MA11.113d:

03/14/2021

This version of the policy will become effective on 03/14/2021.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Diagnostic Coronary Angiography . These guidelines will become effective 03/14/2021. Upon approval, these guidelines are available online http://www.aimspecialtyhealth.com/CG-Cardiology.html.

The summary changes are as follows:

Diagnostic Coronary Angiography

Added criteria to specify appropriate scenarios in individuals with suspected congenital coronary artery anomalies.

Revisions From MA11.113c:

11/10/2019

This version of the policy will become effective 11/10/2019.

The intent of this policy remains unchanged, but the policy has been updated to convey that Arterial Ultrasound is addressed in the AIM Specialty Health® (AIM) Advanced Imaging Clinical Appropriateness Guidelines for Advanced Imaging-Vascular Imaging, which can be found under AIM’s Radiology Guidelines. These guidelines are available online at: http://aimspecialtyhealth.com/CG-Radiology.html. Percutaneous Coronary Intervention and Coronary Angiography services remain under AIM's Cardiology Guidelines.

Revisions From MA11.113b:

06/29/2019

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.

Revisions From MA11.113a:

05/01/2019

This 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].

Revisions From MA11.113:

01/02/2018

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.

Version Effective Date:

9/19/2026

Version Issued Date:

9/21/2026

Version Reissued Date: