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

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.​​

MEDICALLY NECESSARY

Percutaneous transluminal angioplasty (PTA) is considered medically necessary and, therefore, covered when the following criteria are met.

PTA FOR THE TREATMENT OF ATHEROSCLEROTIC OBSTRUCTIVE LESIONS
  • PTA for the treatment of the lower extremities (i.e., the iliac, femoral, and popliteal arteries) or for the upper extremities (i.e., the innominate [the artery that supplies blood to the right arm and head and neck], subclavian, axillary, and brachial arteries); "upper extremities" do not include head or neck vessels.
  • PTA for the treatment of a single coronary artery for individuals for whom the likely alternative treatment is coronary bypass surgery and who exhibit all of the following characteristics:
    • Angina refractory to optimal medical management
    • Objective evidence of myocardial ischemia
    • Lesions amenable to angioplasty
  • PTA for the treatment of the renal arteries for individuals in whom there is an inadequate response to thorough medical management of symptoms and for whom surgery is the likely alternative. PTA for this group of individuals is an alternative to surgery, not simply an addition to medical management.
  • PTA for the treatment of arteriovenous dialysis fistulas and grafts when performed through either a venous or an arterial approach.
PTA OF THE CAROTID ARTERY CONCURRENT WITH CAS IN FDA-APPROVED CATEGORY B INVESTIGATIONAL DEVICE EXEMPTION (IDE) CLINICAL TRIALS
Coverage of PTA of the carotid artery concurrent with carotid stent placement when furnished in accordance with US Food and Drug Administration (FDA)–approved protocols governing category B IDE clinical trials, is considered medically necessary and, therefore, covered.​

PTA OF THE CAROTID ARTERY CONCURRENT WITH CAROTID ARTERY STENT (CAS) PLACEMENT IN FDA-APPROVED POST-APPROVAL STUDIES 
Coverage of PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent and an FDA-approved or FDA-cleared embolic protection device for an FDA-approved indication, when furnished in accordance with FDA-approved protocols governing post-approval studies, is considered medically necessary and, therefore, covered.

​PTA OF THE CAROTID ARTERY CONCURRENT WITH CAS PLACEMENT 

PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent with an FDA-cleared embolic protection is considered medically necessary and, therefore, covered for EITHER of the following indications:

  • Individuals with symptomatic carotid artery stenosis equal to or greater than 50%; OR  
  • Individuals with asymptomatic carotid artery stenosis equal to or greater than 70%​

In addition, ALL of the following criteria must also be met:

  • A neurological assessment by a neurologist or National Institutes of Health Stroke Scale (NIHSS)–certified health professional is performed before and after CAS. 
  • First-line evaluation of carotid artery stenosis using duplex ultrasound. 
  • Computed tomography angiography or magnetic resonance angiography, if not contraindicated, to confirm the degree of stenosis and provide additional information about the aortic arch, and extra- and intracranial circulation.​

NOTE: Intra-arterial digital subtraction (angiography) may be used only when there is significant discrepancy between noninvasive imaging results, or in lieu of computed tomography angiography or magnetic resonance angiography if these are contraindicated.

 

The use of an FDA-approved or FDA-cleared embolic protection device is required. If deployment of the embolic protection device is not technically possible, and not performed, then the procedure is not covered by the Company because it is service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration. 

​Formal Shared-Decision Making 

Prior to furnishing CAS, the professional provider must engage in a formal shared decision-making interaction with the individual. The shared decision-making interaction must include:
  • Discussion of all treatment options including carotid endarterectomy (CEA), CAS (which includes transcarotid artery revascularization [TCAR]), and optimal medical therapy [OMT])
  • Explanation of risks and benefits for each option specific to the individual's clinical situation
  • Integration of clinical guidelines (e.g., individual comorbidities and concomitant treatments)
  • Discussion and incorporation of the individual's personal preferences and priorities in choosing a treatment plan​
Facility Requirements 

Facilities must establish and maintain institutional and physician standards to support a dedicated carotid stent program. These standards must at least include and ensure the following:
  • Facilities have a clearly delineated program for granting carotid stent privileges and for monitoring patient outcomes for individual physicians and the program as a whole.
  • The oversight committee for this program shall be empowered to identify the minimum case volume for a physician to maintain privileges, as well as the (risk-adjusted) threshold for complications that the institution will allow before suspending privileges or instituting measures for remediation. Committees are encouraged to apply published standards from specialty societies and widely used, published professional society guidelines to determine appropriate physician qualifications.
  • Facilities have appropriately trained staff capable of fulfilling roles and responsibilities as delineated under the dedicated carotid stent program.
  • Facilities have appropriate supporting personnel and equipment for imaging, emergency management, advanced physiologic monitoring, and other ancillary care.
  • Facilities must ensure continuous quality improvement by assessing procedural outcomes and making necessary programmatic adjustments to assure patient safety.
​NOT MEDICALLY NECESSARY

EXTRACRANIAL-INTRACRANIAL (EC-IC) ARTERIAL BYPASS SURGERY 
EC-IC arterial bypass surgery is considered not medically necessary and, therefore, not covered when performed as a treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries, including the treatment or prevention of strokes.

EXPERIMENTAL/INVESTIGATIONAL

PTA OF THE INTRACRANIAL ARTERY CONCURRENT WITH INTRACRANIAL STENT PLACEMENT IN FDA-APPROVED CATEGORY B IDE CLINICAL TRIALS 
PTA with stenting of the intracranial arteries for the treatment of cerebral artery stenosis equal to or greater than 50 percent in individuals with intracranial atherosclerotic disease is considered experimental/investigational and, therefore, not covered, with the following exception:
  • Coverage in a qualifying clinical trial approved by Original Medicare, using a category B IDE device performed for PTA and stenting of intracranial arteries for the treatment of cerebral artery stenosis equal to or greater than 50 percent in individuals with intracranial atherosclerotic disease.
COVERAGE OF CLINICAL TRIALS 

Coverage for routine costs associated with qualifying clinical trials for Medicare Advantage members who are enrolled in a clinical trial approved by Medicare are processed through the local Medicare Administrative Contractor (MAC). Therefore:
  • Providers must submit all claims for routine costs associated with qualifying clinical trials to the local MAC.
  • Claims received by the Company for routine costs associated with qualifying clinical trials, including FDA-approved prescription pharmaceuticals, biologics, or devices, are not eligible for reimbursement consideration by the Company.
COVERAGE OF CLINICAL TRIALS USING A CATEGORY B IDE DEVICE: 

Professional providers are responsible for checking the ​Centers for Medicare & Medicaid Services (CMS) Coverage Website to identify whether CMS (or its designated entity) has approved the study for purposes of Medicare coverage prior to billing for the routine costs of a clinical trial and the Category B IDE device. If Original Medicare determines that the device does, in fact, meet the requirements of coverage, and the clinical trial is approved, coverage for the routine costs associated with a qualifying clinical trial and the category B IDE device are processed through the Medicare Advantage plan.

A list of IDE studies meeting CMS’ standards for coverage are listed and maintained on the CMS Coverage website at https://www.cms.gov/Medicare/Coverage/IDE/Approved-IDE-Studies.html.

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

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

Subject to the terms and conditions of the applicable Evidence of Coverage, percutaneous transluminal angioplasty (PTA) is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary or as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Description

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA)

PTA involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. With the development and use of balloon angioplasty for treatment of atherosclerotic and other vascular stenoses, PTA (with and without the placement of a stent) is a widely used technique for dilating lesions of peripheral, coronary, renal, and arteriovenous dialysis fistula and grafts.

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA) CONCURRENT WITH CAROTID ARTERY STENTING (CAS)

PTA with CAS is used as an alternative to CEA. CAS involves the introduction of coaxial systems of catheters, microcatheters, balloons, and other devices. The procedure is most often performed through the femoral artery, but a transcervical approach using direct carotid exposure (i.e., transcarotid artery revascularization [TCAR]) can also be used to avoid traversing the aortic arch. ​Interventional cardiologists almost uniformly use an embolic protection device (EPD) designed to reduce the risk of stroke caused by thromboembolic material dislodged during CAS. Embolic protection devices can be deployed proximally (with flow reversal) or distally (using a filter). Carotid angioplasty rarely is performed without stent placement. ​​

EXTRACRANIAL-INTRACRANIAL (EC-IC) ARTERIAL BYPASS SURGERY

EC-IC arterial bypass surgery is a procedure whose premise is to bypass narrowed arterial segments to improve the blood supply to the brain and reduce the risk of having a stroke. However, the procedure has not been demonstrated to be any more effective than no surgical intervention. Accordingly, EC-IC arterial bypass surgery has not been shown to be effective for the treatment of ischemic cerebrovascular disease of the carotid or middle cerebral arteries.

PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY (PTA) AND INTRACRANIAL STENTING

Intracranial artery stenosis causes approximately eight to ten percent of ischemic cerebrovascular accidents (CVAs or strokes) by restricting blood flow and/or causing embolism. The most common treatment is the use of blood thinners such as antiplatelets (e.g., aspirin) or anticoagulants (e.g., Coumadin®). Intracranial PTA and stenting is a relatively novel approach for the treatment of individuals with refractory, symptomatic intracranial artery stenosis who either continue to have symptoms of a transient ischemic attack (TIA) or develop a CVA while on treatment with antithrombotic medications.

INVESTIGATIONAL DEVICE EXEMPTION (IDE)

An IDE is a regulatory submission that permits clinical investigation of devices. An IDE allows the device to be used in a clinical study in order to collect data on safety and effectiveness that is required to support a Premarket Approval (PMA) application, an HDE, or a Premarket Notification [510(k)] submission to the FDA. Investigational use also includes clinical evaluation of certain modifications or new intended uses of legally marketed devices.

References

​Centers for Medicare & Medicaid Services (CMS). Decision memo for intracranial stenting and angioplasty (CAG-00085R5). [CMS Web site]. 05/12/2008. Available at: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=214&fr​​omdb=true. Accessed October 17, 2023. 

Centers for Medicare & Medicaid Services (CMS). Decision memo for percutaneous transluminal angioplasty (PTA) of the carotid artery concurrent with stenting (CAG-00085R8). [CMS Web site]. 10/11/2023. Available at: NCA - Percutaneous Transluminal Angiopl​asty (PTA) of the Carotid Artery Concurrent with Stenting (CAG-00085R8) - Decision Memo (cms.gov)​​. Accessed October 17, 2023. 

Centers for Medicare & Medicaid Services (CMS). General Information. Carotid artery stenting (CAS) investigational studies. [CMS Web site]. 09/06/2023. Available at:https://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/Carotid-Artery-Stenting-CAS-Investigational-Studies.html. Accessed October 17, 2023. 

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 310.1: Routine costs in clinical trials. [CMS Web site]. 10/09/2007. Available at:
https://www.cms.gov/medicare-cov​erage-database/details/ncd-details.aspx?NCDId=1&ncdver=2&DocID=310.1&bc=gAAAAAgAAAAAAA==&. Accessed October 17, 2023. 

Centers for Medicare & Medicaid Services (CMS). Approved IDE Studies. [CMS Web site]. 09/06/2023. Available at: https://www.cms.gov/medicare/coverage/IDE/index.html. Accessed October 17, 2023. 

Centers for Medicare & Medicaid Services (CMS). Medicare coverage related to investigational device exemption (IDE) studies. Pivotal study of the MicroVention, Inc. Carotid Artery Stent System used in conjunction with the Nanoparasol® Embolic Protection System for the treatment of carotid artery stenosis in patients at elevated risk for adverse events from carotid endarterectomy.(CONFIDENCE Trial). [CMS Web site]. 07/07/2016. Available at:
https://www.cms.gov/Medicare/Coverage/IDE/Approved-IDE-Studies-Items/G140249-NCT02657707-.html?DLPage=1&DLEntries=10&DLFilter=Carotid artery &DLSort=2&DLSortDir=ascending.Accessed October 17, 2023. 

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 20.2: Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery. [CMS Web site]. 03/27/1991. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?MCDId=17&ExpandComments=n&McdName=Clinical+Pharmacology+Compendium+Revision+Request+-+CAG-00392&mcdtypename=Compendia&MCDIndexType=6&NCDId=54&ncdver=1&bc=AgAEAAAAAgAA&. Accessed October 17, 2023.

Coding

CPT Procedure Code Number(s)
​MEDICALLY NECESSARY

37215
37218
37246
37247
​37254
​37255
​37256
​37257
​37258
​37259
​37260
​37261
​37263
​37264
​37265
​37266
​37267
​37268
​37269
​37270
​37271
​37272
​37273
​37274
​37275
​37276
​37277
​37278
​37280
​37281
​37282
​37283
​37284
​37285
​37286
​37287
​37288
​37289
​37290
​37291
​37292
​37293
​37294
​37295
​37296
​37297
​37298
​37299
92920
92924
92928
​92930
92933
92937
92941
92943​
​92945

THE FOLLOWING CODE IS USED TO REPRESENT PERCUTANEOUS TRANSCATHETER PLACEMENT OF A CAROTID ARTERY STENT WITH ​PROXIMAL EMBOLIC PROTECTION

37799

NOT MEDICALLY NECESSARY

37216
61711

EXPERIMENTAL/INVESTIGATIONAL

​61630
61635​
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
I63.031     Cerebral infarction due to thrombosis of right carotid artery
I63.032     Cerebral infarction due to thrombosis of left carotid artery
​I63.033 Cerebral infarction due to thrombosis of bilateral carotid arteries
I63.131     Cerebral infarction due to embolism of right carotid artery
I63.132     Cerebral infarction due to embolism of left carotid artery
I63.133 Cerebral infarction due to embolism of bilateral carotid arteries​
I63.211     Cerebral infarction due to unspecified occlusion or stenosis of right vertebral artery
I63.212     Cerebral infarction due to unspecified occlusion or stenosis of left vertebral artery
I63.213     Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries
I63.22       Cerebral infarction due to unspecified occlusion or stenosis of basilar artery
I63.29       Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries
I63.231     Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries
I63.232     Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries
I63.233     Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries
I63.511     Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery
I63.512     Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery
I63.513     Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries
I63.521     Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery
I63.522     Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery
I63.523     Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries
I63.531     Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery
I63.532     Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery
I63.533     Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior cerebral arteries
I63.541     Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery
I63.542     Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery
I63.543     Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries
I63.59       Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery
I65.01       Occlusion and stenosis of right vertebral artery
I65.02       Occlusion and stenosis of left vertebral artery
I65.03       Occlusion and stenosis of bilateral vertebral arteries
I65.1         Occlusion and stenosis of basilar artery
I65.21       Occlusion and stenosis of right carotid artery
I65.22       Occlusion and stenosis of left carotid artery
I65.23       Occlusion and stenosis of bilateral carotid arteries
I66.01       Occlusion and stenosis of right middle cerebral artery
I66.02       Occlusion and stenosis of left middle cerebral artery
I66.03       Occlusion and stenosis of bilateral middle cerebral arteries
I66.11       Occlusion and stenosis of right anterior cerebral artery
I66.12       Occlusion and stenosis of left anterior cerebral artery
I66.13       Occlusion and stenosis of bilateral anterior cerebral arteries
I66.21       Occlusion and stenosis of right posterior cerebral artery
I66.22       Occlusion and stenosis of left posterior cerebral artery
I66.23       Occlusion and stenosis of bilateral posterior cerebral arteries
I66.3         Occlusion and stenosis of cerebellar arteries
I66.8         Occlusion and stenosis of other cerebral arteries
I66.9         Occlusion and stenosis of unspecified cerebral artery
I67.2         Cerebral atherosclerosis
I67.82       Cerebral ischemia
I67.858     Other hereditary cerebrovascular disease
HCPCS Level II Code Number(s)

C1884 Embolization protective system

C7531 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation

C7532 Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), initial artery, open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation

C7534 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performed with intravascular ultrasound (initial noncoronary vessel) durin g diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation

C7535 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilat eral, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation​

Revenue Code Number(s)
N/A


​

Coding and Billing Requirements

Policy History

Revisions From MA11.056i:​
​04/01/2026
​This policy has been reissued in accordance with the Company's annual review process.
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:
92920, 92924, 92928, 92933, 92937, 92941, 92943

The following CPT codes have been added:
37254-37261, 37263-37278, 37280-37299, 92930, 92945

The following CPT codes have been termed​:
37220-37235, 92921, 92925, 92929, 92934, 92938, 92944

Revisions From MA11.056h:
04/02/2025
​This policy has been reissued in accordance with the Company's annual review process.​
04/08/2024
​This version of the policy will become effective 04/08/2024. The intent of this policy remains unchanged; however, policy criteria for percutaneous transluminal angioplasty (PTA) of the carotid artery with concurrent stenting has been revised in accordance with the Centers for Medicare & Medicaid Services (CMS) Decision memo for Percutaneous Transluminal Angioplasty (PTA) of the Carotid Artery Concurrent with Stenting ​(CAG-00085R8)​ 10/11/2023,​ which expands coverage:
  • ​to individuals previously only eligible for coverage in clinical trials
  • to standard surgical risk individuals by removing the limitation of coverage to only high-surgical-risk individuals​
In addition, the criteria for category B IDE trials was revised.

Revisions From MA11.056g:
​01/01/2024
​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​​​

08/09/2023

This policy has been reissued in accordance with the Company's annual review process.

​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.
 
This policy has been identified for the HCPCS code update, effective 01/01/2023.

The following HCPCS codes have been added to this policy:

C7531 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation


C7532 Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), initial artery, open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation​


C7534 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performed with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation


C7535 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation​


Revisions From MA11.056f:
​10/05/2022
​The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting and Extracranial- intracranial (EC-IC) Arterial Bypass Surgery.​​

07/19/2021

​This version of the policy will become effective 07/19/2021. The intent of this policy remains unchanged; however, a not otherwise specified CPT code has been incorporated to represent proximal embolic protection devices performed in conjuction with carotid artery stenting (CAS). ​ 

The Company’s coverage position has changed from Experimental/Investigational to Medically Necessary for this service:

PERCUTANEOUS TRANSCATHETER PLACEMENT OF A CAROTID ARTERY STENT WITH PROXIMAL EMBOLIC PROTECTION 

The following CPT code has been added to this policy: 
  • ​37799​

Revisions From MA11.056e:

03/10/202​1

The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting and Extracranial- intracranial (EC-IC) Arterial Bypass Surgery.​
​12/18/2019​This policy has been reissued in accordance with the Company's annual review process.
​10/01/2018​The following ICD-10 CM narratives have been revised in this policy:

I63.219

FROM: Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral artery

I63.239
FROM: Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery

The following ICD-10 CM code has been added to this policy:
I67.858 Other hereditary cerebrovascular disease

Revisions From MA11.056d:
01/31/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on percutaneous transluminal angioplasty (PTA) concurrent with or without stenting and extracranial- intracranial (EC-IC) arterial bypass surgery
11/22/2017This policy has been reissued in accordance with the Company's annual review process.
10/01/2017This version of the policy will become effective 10/01/2017.

The following ICD-10 CM narratives have been revised in this policy:

I63.211:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of right vertebral arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of right vertebral artery

I63.212:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of left vertebral arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of left vertebral artery


I63.22:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of basilar artery


I63.513:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries


I63.523:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries


I63.533:
FROM: Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior arteries
TO: Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior cerebral arteries

Revisions From MA11.056c:
01/01/2017This version of the policy will become effective 01/01/2017.

The following CPT codes have been deleted from this policy:
35471, 35472, 35475, 35476

The following CPT codes have been added to this policy:
37246, 37247

Revisions From MA11.056b:
10/01/2016This version of the policy will become effective 10/01/2016.

The intent of this policy remains unchanged; however, statement revised for coverage of clinical trials using a category B investigation device exemption (IDE).

This policy has been identified for the ICD-10 CM code update, effective 10/01/2016.

The following ICD-10 CM codes have been added to this policy (Medically necessary):

I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries
I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries
I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle arteries
I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior arteries
I63.533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior arteries
I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries

The following CPT codes have been removed from this policy, since they are not clinically appropriate for the scope of this policy:

0075T
0076T

The following ICD-10 CM codes have been removed from this policy, since they are not clinically appropriate for the scope of this policy:

I63.20 Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral arteries
I65.8 Occlusion and stenosis of other precerebral arteries
I65.9 Occlusion and stenosis of unspecified precerebral artery

The following Modifiers have been removed from this policy since they are informational only:

LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LM Left main coronary artery
RC Right coronary artery
RI Ramus intermedius coronary artery

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

I66.19 Occlusion and stenosis of unspecified anterior cerebral artery

The following HCPCS Level II code has been added to this policy:

C1884 Embolization protective system

Revisions From MA11.056a:
10/02/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Transluminal Angioplasty (PTA) and Extracranial (EC) and Intracranial (IC) Arterial Bypass Surgery.
10/01/2015Applicable ICD-10 CM codes have been added to the policy.

Revisions From MA11.056:
01/01/2015This is a new policy. This policy has been identified for the CPT code update, effective 01/01/2015.

The following CPT code has been added to the policy: 37218

The following CPT narratives have been revised in the policy: 0075T, 0076T, 37215, 37216
1/1/2026
1/2/2026
4/1/2026
MA11.056
Medical Policy Bulletin
Medicare Advantage
No
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