Clinical UM Guideline



Subject: Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
Guideline #:  CG-SURG-49 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

Description

This document addresses the use of peripheral vascular angioplasty, with and without stenting, and with or without atherectomy, for the treatment of occlusive peripheral arterial disease (PAD) of the lower extremities. 

Note: Procedures to address venous peripheral vascular disease are NOT addressed in this document.

Note: Please see the following document for additional information:

Clinical Indications

A.  Treatment of Claudication

Medically Necessary:

For individuals with claudication due to lower extremity occlusive arterial disease, the use of either percutaneous or open exposure angioplasty is considered medically necessary for individuals who meet the ALL of the following criteria:

  1. Presence of severe disability (inability to perform usual work or life-style activities) due to intermittent claudication; and
  2. There has been an inadequate response to at least 6 months of conservative treatment including lifestyle initiatives for known risks (for example, smoking cessation and dietary changes), including supervised exercise training, and pharmacological therapy (for example, anti-platelet, cilostazol) unless contraindicated; and
  3. The targeted PAD lesion is a TASC type A (single stenosis of less than 3 cm) of the common iliac, external iliac, or femoropopliteal artery (unilateral or bilateral); and
  4. There is an absence of other conditions that would limit exercise even if the claudication were improved (for example, angina or chronic pulmonary disease) with the endovascular intervention.

For individuals with claudication due to lower extremity occlusive arterial disease, the use of either percutaneous or open exposure primary stent placement is considered medically necessary, when the following criteria have been met:

  1. Stenosis or occlusion is present in either the common iliac or external iliac artery; and
  2. Criteria above for angioplasty have been met.

For individuals with claudication due to lower extremity occlusive arterial disease, the use of either percutaneous or open exposure stents or atherectomy devices as salvage (provisional) therapy for a suboptimal or failed result from balloon angioplasty is considered medically necessary when the residual stenosis or occlusion is present in either the femoral, popliteal, or tibial artery and ANY the following criteria have been met:

  1. Residual diameter stenosis greater than 50%; or
  2. Persistent translesional pressure gradient; or
  3. Flow-limiting dissection is present.

Not Medically Necessary:

The use of percutaneous or open exposure angioplasty, with or without stent placement, and with or without atherectomy for the treatment of individuals with claudication due to lower extremity occlusive arterial disease is considered not medically necessary when the criteria above have not been met, including its use as prophylactic therapy in an asymptomatic individual with lower extremity PAD.

The use of primary stent placement for the treatment of claudication caused by a lesion in the femoral, popliteal, or tibial arteries is considered not medically necessary.

B.  Critical Limb Ischemia (CLI)

Medically Necessary:

For individuals with limb threatening CLI due to lower extremity occlusive arterial disease (ischemic rest pain and/or impending limb loss with skin ulceration, gangrene, infection) of the lower extremity, the use of endovascular procedures (angioplasty, stent placement, or atherectomy) is considered medically necessary as initial or salvage therapy for inflow (aorto-iliac) and outflow (infrainguinal) occlusive vascular disease.

Note: The optimal strategy for the management of an individual with CLI is determined on a case by case basis by the treating physician and influenced by the urgency of the limb threat, comorbidities, and the individual's arterial anatomy. 

Not Medically Necessary:

The use of endovascular procedures (angioplasty, stent placement, or atherectomy) for the treatment of CLI due to lower extremity occlusive arterial disease is considered not medically necessary as initial or salvage therapy for inflow (aorto-iliac) and outflow (infrainguinal) occlusive vascular disease in the absence of clinical symptoms of limb threatening CLI and the medically necessary criteria for treatment of claudication above are not met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT  
37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty
37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty
37223 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed 
37224 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty
37225 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed
37226 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
37227 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
37228 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty
37229 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed
37230 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
37231 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
37232 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty 
37233 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)
37234 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)
37235 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
   
ICD-10 Procedure  
047C041-047C4ZZ Dilation of right common iliac artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices, or drug-coated balloon, by approach; includes codes 047C041, 047C046, 047C04Z, 047C056, 047C05Z, 047C066, 047C06Z, 047C076, 047C07Z, 047C0D1, 047C0D6, 047C0DZ, 047C0E6, 047C0EZ, 047C0F6, 047C0FZ, 047C0G6, 047C0GZ, 047C0Z1, 047C0Z6, 047C0ZZ, 047C341, 047C346, 047C34Z, 047C356, 047C35Z, 047C366, 047C36Z, 047C376, 047C37Z, 047C3D1, 047C3D6, 047C3DZ, 047C3E6, 047C3EZ, 047C3F6, 047C3FZ, 047C3G6, 047C3GZ, 047C3Z1, 047C3Z6, 047C3ZZ, 047C441, 047C446, 047C44Z, 047C456, 047C45Z, 047C466, 047C46Z, 047C476, 047C47Z, 047C4D1, 047C4D6, 047C4DZ, 047C4E6, 047C4EZ, 047C4F6, 047C4FZ, 047C4G6, 047C4GZ, 047C4Z1, 047C4Z6, 047C4ZZ]
047D041-047D4ZZ Dilation of left common iliac artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047D041, 047D046, 047D04Z, 047D056, 047D05Z, 047D066, 047D06Z, 047D076, 047D07Z, 047D0D1, 047D0D6, 047D0DZ, 047D0E6, 047D0EZ, 047D0F6, 047D0FZ, 047D0G6, 047D0GZ, 047D0Z1, 047D0Z6, 047D0ZZ, 047D341, 047D346, 047D34Z, 047D356, 047D35Z, 047D366, 047D36Z, 047D376, 047D37Z, 047D3D1, 047D3D6, 047D3DZ, 047D3E6, 047D3EZ, 047D3F6, 047D3FZ, 047D3G6, 047D3GZ, 047D3Z1, 047D3Z6, 047D3ZZ, 047D441, 047D446, 047D44Z, 047D456, 047D45Z, 047D466, 047D46Z, 047D476, 047D47Z, 047D4D1, 047D4D6, 047D4DZ, 047D4E6, 047D4EZ, 047D4F6, 047D4FZ, 047D4G6, 047D4GZ, 047D4Z1, 047D4Z6, 047D4ZZ]
047E041-047E4ZZ Dilation of right internal iliac artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047E041, 047E046, 047E04Z, 047E056, 047E05Z, 047E066, 047E06Z, 047E076, 047E07Z, 047E0D1, 047E0D6, 047E0DZ, 047E0E6, 047E0EZ, 047E0F6, 047E0FZ, 047E0G6, 047E0GZ, 047E0Z1, 047E0Z6, 047E0ZZ, 047E341, 047E346, 047E34Z, 047E356, 047E35Z, 047E366, 047E36Z, 047E376, 047E37Z, 047E3D1, 047E3D6, 047E3DZ, 047E3E6, 047E3EZ, 047E3F6, 047E3FZ, 047E3G6, 047E3GZ, 047E3Z1, 047E3Z6, 047E3ZZ, 047E441, 047E446, 047E44Z, 047E456, 047E45Z, 047E466, 047E46Z, 047E476, 047E47Z, 047E4D1, 047E4D6, 047E4DZ, 047E4E6, 047E4EZ, 047E4F6, 047E4FZ, 047E4G6, 047E4GZ, 047E4Z1, 047E4Z6, 047E4ZZ]
047F041-047F4ZZ Dilation of left internal iliac artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047F041, 047F046, 047F04Z, 047F056, 047F05Z, 047F066, 047F06Z, 047F076, 047F07Z, 047F0D1, 047F0D6, 047F0DZ, 047F0E6, 047F0EZ, 047F0F6, 047F0FZ, 047F0G6, 047F0GZ, 047F0Z1, 047F0Z6, 047F0ZZ, 047F341, 047F346, 047F34Z, 047F356, 047F35Z, 047F366, 047F36Z, 047F376, 047F37Z, 047F3D1, 047F3D6, 047F3DZ, 047F3E6, 047F3EZ, 047F3F6, 047F3FZ, 047F3G6, 047F3GZ, 047F3Z1, 047F3Z6, 047F3ZZ, 047F441, 047F446, 047F44Z, 047F456, 047F45Z, 047F466, 047F46Z, 047F476, 047F47Z, 047F4D1, 047F4D6, 047F4DZ, 047F4E6, 047F4EZ, 047F4F6, 047F4FZ, 047F4G6, 047F4GZ, 047F4Z1, 047F4Z6, 047F4ZZ]
047H041-047H4ZZ Dilation of right external iliac artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047H041, 047H046, 047H04Z, 047H056, 047H05Z, 047H066, 047H06Z, 047H076, 047H07Z, 047H0D1, 047H0D6, 047H0DZ, 047H0E6, 047H0EZ, 047H0F6, 047H0FZ, 047H0G6, 047H0GZ, 047H0Z1, 047H0Z6, 047H0ZZ, 047H341, 047H346, 047H34Z, 047H356, 047H35Z, 047H366, 047H36Z, 047H376, 047H37Z, 047H3D1, 047H3D6, 047H3DZ, 047H3E6, 047H3EZ, 047H3F6, 047H3FZ, 047H3G6, 047H3GZ, 047H3Z1, 047H3Z6, 047H3ZZ, 047H441, 047H446, 047H44Z, 047H456, 047H45Z, 047H466, 047H46Z, 047H476, 047H47Z, 047H4D1, 047H4D6, 047H4DZ, 047H4E6, 047H4EZ, 047H4F6, 047H4FZ, 047H4G6, 047H4GZ, 047H4Z1, 047H4Z6, 047H4ZZ]
047J041-047J4ZZ Dilation of left external iliac artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047J041, 047J046, 047J04Z, 047J056, 047J05Z, 047J066, 047J06Z, 047J076, 047J07Z, 047J0D1, 047J0D6, 047J0DZ, 047J0E6, 047J0EZ, 047J0F6, 047J0FZ, 047J0G6, 047J0GZ, 047J0Z1, 047J0Z6, 047J0ZZ, 047J341, 047J346, 047J34Z, 047J356, 047J35Z, 047J366, 047J36Z, 047J376, 047J37Z, 047J3D1, 047J3D6, 047J3DZ, 047J3E6, 047J3EZ, 047J3F6, 047J3FZ, 047J3G6, 047J3GZ, 047J3Z1, 047J3Z6, 047J3ZZ, 047J441, 047J446, 047J44Z, 047J456, 047J45Z, 047J466, 047J46Z, 047J476, 047J47Z, 047J4D1, 047J4D6, 047J4DZ, 047J4E6, 047J4EZ, 047J4F6, 047J4FZ, 047J4G6, 047J4GZ, 047J4Z1, 047J4Z6, 047J4ZZ]
047K041-047K4ZZ Dilation of right femoral artery or bifurcation [with or without drug-eluting device, drug-coated balloon or other intraluminal device and number of devices, by approach; includes codes 047K041, 047K046, 047K04Z, 047K056, 047K05Z, 047K066, 047K06Z, 047K076, 047K07Z, 047K0D1, 047K0D6, 047K0DZ, 047K0E6, 047K0EZ, 047K0F6, 047K0FZ, 047K0G6, 047K0GZ, 047K0Z1, 047K0Z6, 047K0ZZ, 047K341, 047K346, 047K34Z, 047K356, 047K35Z, 047K366, 047K36Z, 047K376, 047K37Z, 047K3D1, 047K3D6, 047K3DZ, 047K3E6, 047K3EZ, 047K3F6, 047K3FZ, 047K3G6, 047K3GZ, 047K3Z1, 047K3Z6, 047K3ZZ, 047K441, 047K446, 047K44Z, 047K456, 047K45Z, 047K466, 047K46Z, 047K476, 047K47Z, 047K4D1, 047K4D6, 047K4DZ, 047K4E6, 047K4EZ, 047K4F6, 047K4FZ, 047K4G6, 047K4GZ, 047K4Z1, 047K4Z6, 047K4ZZ]
047L041-047L4ZZ Dilation of left femoral artery or bifurcation [with or without drug-eluting device, drug-coated balloon or other intraluminal device and number of devices, by approach; includes codes 047L041, 047L046, 047L04Z, 047L056, 047L05Z, 047L066, 047L06Z, 047L076, 047L07Z, 047L0D1, 047L0D6, 047L0DZ, 047L0E6, 047L0EZ, 047L0F6, 047L0FZ, 047L0G6, 047L0GZ, 047L0Z1, 047L0Z6, 047L0ZZ, 047L341, 047L346, 047L34Z, 047L356, 047L35Z, 047L366, 047L36Z, 047L376, 047L37Z, 047L3D1, 047L3D6, 047L3DZ, 047L3E6, 047L3EZ, 047L3F6, 047L3FZ, 047L3G6, 047L3GZ, 047L3Z1, 047L3Z6, 047L3ZZ, 047L441, 047L446, 047L44Z, 047L456, 047L45Z, 047L466, 047L46Z, 047L476, 047L47Z, 047L4D1, 047L4D6, 047L4DZ, 047L4E6, 047L4EZ, 047L4F6, 047L4FZ, 047L4G6, 047L4GZ, 047L4Z1, 047L4Z6, 047L4ZZ]
047M041-047M4ZZ Dilation of right popliteal artery or bifurcation [with or without drug-eluting device, drug-coated balloon or other intraluminal device and number of devices, by approach; includes codes 047M041, 047M046, 047M04Z, 047M056, 047M05Z, 047M066, 047M06Z, 047M076, 047M07Z, 047M0D1, 047M0D6, 047M0DZ, 047M0E6, 047M0EZ, 047M0F6, 047M0FZ, 047M0G6, 047M0GZ, 047M0Z1, 047M0Z6, 047M0ZZ, 047M341, 047M346, 047M34Z, 047M356, 047M35Z, 047M366, 047M36Z, 047M376, 047M37Z, 047M3D1, 047M3D6, 047M3DZ, 047M3E6, 047M3EZ, 047M3F6, 047M3FZ, 047M3G6, 047M3GZ, 047M3Z1, 047M3Z6, 047M3ZZ, 047M441, 047M446, 047M44Z, 047M456, 047M45Z, 047M466, 047M46Z, 047M476, 047M47Z, 047M4D1, 047M4D6, 047M4DZ, 047M4E6, 047M4EZ, 047M4F6, 047M4FZ, 047M4G6, 047M4GZ, 047M4Z1, 047M4Z6, 047M4ZZ]
047N041-047N4ZZ Dilation of left popliteal artery or bifurcation [with or without drug-eluting device, drug-coated balloon or other intraluminal device and number of devices, by approach; includes codes 047N041, 047N046, 047N04Z, 047N056, 047N05Z, 047N066, 047N06Z, 047N076, 047N07Z, 047N0D1, 047N0D6, 047N0DZ, 047N0E6, 047N0EZ, 047N0F6, 047N0FZ, 047N0G6, 047N0GZ, 047N0Z1, 047N0Z6, 047N0ZZ, 047N341, 047N346, 047N34Z, 047N356, 047N35Z, 047N366, 047N36Z, 047N376, 047N37Z, 047N3D1, 047N3D6, 047N3DZ, 047N3E6, 047N3EZ, 047N3F6, 047N3FZ, 047N3G6, 047N3GZ, 047N3Z1, 047N3Z6, 047N3ZZ, 047N441, 047N446, 047N44Z, 047N456, 047N45Z, 047N466, 047N46Z, 047N476, 047N47Z, 047N4D1, 047N4D6, 047N4DZ, 047N4E6, 047N4EZ, 047N4F6, 047N4FZ, 047N4G6, 047N4GZ, 047N4Z1, 047N4Z6, 047N4ZZ]
047P041-047P4ZZ Dilation of right anterior tibial artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047P041, 047P046, 047P04Z, 047P056, 047P05Z, 047P066, 047P06Z, 047P076, 047P07Z, 047P0D1, 047P0D6, 047P0DZ, 047P0E6, 047P0EZ, 047P0F6, 047P0FZ, 047P0G6, 047P0GZ, 047P0Z1, 047P0Z6, 047P0ZZ, 047P341, 047P346, 047P34Z, 047P356, 047P35Z, 047P366, 047P36Z, 047P376, 047P37Z, 047P3D1, 047P3D6, 047P3DZ, 047P3E6, 047P3EZ, 047P3F6, 047P3FZ, 047P3G6, 047P3GZ, 047P3Z1, 047P3Z6, 047P3ZZ, 047P441, 047P446, 047P44Z, 047P456, 047P45Z, 047P466, 047P46Z, 047P476, 047P47Z, 047P4D1, 047P4D6, 047P4DZ, 047P4E6, 047P4EZ, 047P4F6, 047P4FZ, 047P4G6, 047P4GZ, 047P4Z1, 047P4Z6, 047P4ZZ]
047Q041-047Q4ZZ Dilation of left anterior tibial artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047Q041, 047Q046, 047Q04Z, 047Q056, 047Q05Z, 047Q066, 047Q06Z, 047Q076, 047Q07Z, 047Q0D1, 047Q0D6, 047Q0DZ, 047Q0E6, 047Q0EZ, 047Q0F6, 047Q0FZ, 047Q0G6, 047Q0GZ, 047Q0Z1, 047Q0Z6, 047Q0ZZ, 047Q341, 047Q346, 047Q34Z, 047Q356, 047Q35Z, 047Q366, 047Q36Z, 047Q376, 047Q37Z, 047Q3D1, 047Q3D6, 047Q3DZ, 047Q3E6, 047Q3EZ, 047Q3F6, 047Q3FZ, 047Q3G6, 047Q3GZ, 047Q3Z1, 047Q3Z6, 047Q3ZZ, 047Q441, 047Q446, 047Q44Z, 047Q456, 047Q45Z, 047Q466, 047Q46Z, 047Q476, 047Q47Z, 047Q4D1, 047Q4D6, 047Q4DZ, 047Q4E6, 047Q4EZ, 047Q4F6, 047Q4FZ, 047Q4G6, 047Q4GZ, 047Q4Z1, 047Q4Z6, 047Q4ZZ]
047R041-047R4ZZ Dilation of right posterior tibial artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047R041, 047R046, 047R04Z, 047R056, 047R05Z, 047R066, 047R06Z, 047R076, 047R07Z, 047R0D1, 047R0D6, 047R0DZ, 047R0E6, 047R0EZ, 047R0F6, 047R0FZ, 047R0G6, 047R0GZ, 047R0Z1, 047R0Z6, 047R0ZZ, 047R341, 047R346, 047R34Z, 047R356, 047R35Z, 047R366, 047R36Z, 047R376, 047R37Z, 047R3D1, 047R3D6, 047R3DZ, 047R3E6, 047R3EZ, 047R3F6, 047R3FZ, 047R3G6, 047R3GZ, 047R3Z1, 047R3Z6, 047R3ZZ, 047R441, 047R446, 047R44Z, 047R456, 047R45Z, 047R466, 047R46Z, 047R476, 047R47Z, 047R4D1, 047R4D6, 047R4DZ, 047R4E6, 047R4EZ, 047R4F6, 047R4FZ, 047R4G6, 047R4GZ, 047R4Z1, 047R4Z6, 047R4ZZ]
047S041-047S4ZZ Dilation of left posterior tibial artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047S041, 047S046, 047S04Z, 047S056, 047S05Z, 047S066, 047S06Z, 047S076, 047S07Z, 047S0D1, 047S0D6, 047S0DZ, 047S0E6, 047S0EZ, 047S0F6, 047S0FZ, 047S0G6, 047S0GZ, 047S0Z1, 047S0Z6, 047S0ZZ, 047S341, 047S346, 047S34Z, 047S356, 047S35Z, 047S366, 047S36Z, 047S376, 047S37Z, 047S3D1, 047S3D6, 047S3DZ, 047S3E6, 047S3EZ, 047S3F6, 047S3FZ, 047S3G6, 047S3GZ, 047S3Z1, 047S3Z6, 047S3ZZ, 047S441, 047S446, 047S44Z, 047S456, 047S45Z, 047S466, 047S46Z, 047S476, 047S47Z, 047S4D1, 047S4D6, 047S4DZ, 047S4E6, 047S4EZ, 047S4F6, 047S4FZ, 047S4G6, 047S4GZ, 047S4Z1, 047S4Z6, 047S4ZZ]
047T041-047T4ZZ Dilation of right peroneal artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047T041, 047T046, 047T04Z, 047T056, 047T05Z, 047T066, 047T06Z, 047T076, 047T07Z, 047T0D1, 047T0D6, 047T0DZ, 047T0E6, 047T0EZ, 047T0F6, 047T0FZ, 047T0G6, 047T0GZ, 047T0Z1, 047T0Z6, 047T0ZZ, 047T341, 047T346, 047T34Z, 047T356, 047T35Z, 047T366, 047T36Z, 047T376, 047T37Z, 047T3D1, 047T3D6, 047T3DZ, 047T3E6, ,047T3EZ 047T3F6, 047T3FZ, 047T3G6, 047T3GZ, 047T3Z1, 047T3Z6, 047T3ZZ, 047T441, 047T446, 047T44Z, 047T456, 047T45Z, 047T466, 047T46Z, 047T476, 047T47Z, 047T4D1, 047T4D6, 047T4DZ, 047T4E6, 047T4EZ, 047T4F6, 047T4FZ, 047T4G6, 047T4GZ, 047T4Z1, 047T4Z6, 047T4ZZ]
047U041-047U4ZZ Dilation of left peroneal artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047U041, 047U046, 047U04Z, 047U056, 047U05Z, 047U066, 047U06Z, 047U076, 047U07Z, 047U0D1, 047U0D6, 047U0DZ, 047U0E6, 047U0EZ, 047U0F6, 047U0FZ, 047U0G6, 047U0GZ, 047U0Z1, 047U0Z6, 047U0ZZ, 047U341, 047U346, 047U34Z, 047U356, 047U35Z, 047U366, 047U36Z, 047U376, 047U37Z, 047U3D1, 047U3D6, 047U3DZ, 047U3E6, 047U3EZ, 047U3F6, 047U3FZ, 047U3G6, 047U3GZ, 047U3Z1, 047U3Z6, 047U3ZZ, 047U441, 047U446, 047U44Z, 047U456, 047U45Z, 047U466, 047U46Z, 047U476, 047U47Z, 047U4D1, 047U4D6, 047U4DZ, 047U4E6, 047U4EZ, 047U4F6, 047U4FZ, 047U4G6, 047U4GZ, 047U4Z1, 047U4Z6, 047U4ZZ]
047V041-047V4ZZ Dilation of right foot artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047V041, 047V046, 047V04Z, 047V056, 047V05Z, 047V066, 047V06Z, 047V076, 047V07Z, 047V0D1, 047V0D6, 047V0DZ, 047V0E6, 047V0EZ, 047V0F6, 047V0FZ, 047V0G6, 047V0GZ, 047V0Z1, 047V0Z6, 047V0ZZ, 047V341, 047V346, 047V34Z, 047V356, 047V35Z, 047V366, 047V36Z, 047V376, 047V37Z, 047V3D1, 047V3D6, 047V3DZ, 047V3E6, 047V3EZ, 047V3F6, 047V3FZ, 047V3G6, 047V3GZ, 047V3Z1, 047V3Z6, 047V3ZZ, 047V441, 047V446, 047V44Z, 047V456, 047V45Z, 047V466, 047V46Z, 047V476, 047V47Z, 047V4D1, 047V4D6, 047V4DZ, 047V4E6, 047V4EZ, 047V4F6, 047V4FZ, 047V4G6, 047V4GZ, 047V4Z1, 047V4Z6, 047V4ZZ]
047W041-047W4ZZ Dilation of left foot artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047W041, 047W046, 047W04Z, 047W056, 047W05Z, 047W066, 047W06Z, 047W076, 047W07Z, 047W0D1, 047W0D6, 047W0DZ, 047W0E6, 047W0EZ, 047W0F6, 047W0FZ, 047W0G6, 047W0GZ, 047W0Z1, 047W0Z6, 047W0ZZ, 047W341, 047W346, 047W34Z, 047W356, 047W35Z, 047W366, 047W36Z, 047W376, 047W37Z, 047W3D1, 047W3D6, 047W3DZ, 047W3E6, 047W3EZ, 047W3F6, 047W3FZ, 047W3G6, 047W3GZ, 047W3Z1, 047W3Z6, 047W3ZZ, 047W441, 047W446, 047W44Z, 047W456, 047W45Z, 047W466, 047W46Z, 047W476, 047W47Z, 047W4D1, 047W4D6, 047W4DZ, 047W4E6, 047W4EZ, 047W4F6, 047W4FZ, 047W4G6, 047W4GZ, 047W4Z1, 047W4Z6, 047W4ZZ]
047Y041-047Y4ZZ Dilation of lower artery or bifurcation [with or without drug-eluting or other intraluminal device and number of devices or drug-coated balloon, by approach; includes codes 047Y041, 047Y046, 047Y04Z, 047Y056, 047Y05Z, 047Y066, 047Y06Z, 047Y076, 047Y07Z, 047Y0D1, 047Y0D6, 047Y0DZ, 047Y0E6, 047Y0EZ, 047Y0F6, 047Y0FZ, 047Y0G6, 047Y0GZ, 047Y0Z1, 047Y0Z6, 047Y0ZZ, 047Y341, 047Y346, 047Y34Z, 047Y356, 047Y35Z, 047Y366, 047Y36Z, 047Y376, 047Y37Z, 047Y3D1, 047Y3D6, 047Y3DZ, 047Y3E6, 047Y3EZ, 047Y3F6, 047Y3FZ, 047Y3G6, 047Y3GZ, 047Y3Z1, 047Y3Z6, 047Y3ZZ, 047Y441, 047Y446, 047Y44Z, 047Y456, 047Y45Z, 047Y466, 047Y46Z, 047Y476, 047Y47Z, 047Y4D1, 047Y4D6, 047Y4DZ, 047Y4E6, 047Y4EZ, 047Y4F6, 047Y4FZ, 047Y4G6, 047Y4GZ, 047Y4Z1, 047Y4Z6, 047Y4ZZ]
04CC0Z6-04CD4ZZ Extirpation of matter from common iliac artery or bifurcation [right or left, by approach; includes codes 04CC0Z6, 04CC0ZZ, 04CC3Z6, 04CC3ZZ, 04CC4Z6, 04CC4ZZ, 04CD0Z6, 04CD0ZZ, 04CD3Z6, 04CD3ZZ, 04CD4Z6, 04CD4ZZ]
04CE0Z6-04CF4ZZ Extirpation of matter from internal iliac artery or bifurcation [right or left, by approach; includes codes 04CE0Z6, 04CE0ZZ, 04CE3Z6, 04CE3ZZ, 04CE4Z6, 04CE4ZZ, 04CF0Z6, 04CF0ZZ, 04CF3Z6, 04CF3ZZ, 04CF4Z6, 04CF4ZZ]
04CH0Z6-04CJ4ZZ Extirpation of matter from external iliac artery or bifurcation [right or left, by approach; includes codes 04CH0Z6, 04CH0ZZ, 04CH3Z6, 04CH3ZZ, 04CH4Z6, 04CH4ZZ, 04CJ0Z6, 04CJ0ZZ, 04CJ3Z6, 04CJ3ZZ, 04CJ4Z6, 04CJ4ZZ]
04CK0Z6-04CL4ZZ Extirpation of matter from femoral artery or bifurcation [right or left, by approach; includes codes 04CK0Z6, 04CK0ZZ, 04CK3Z6, 04CK3ZZ, 04CK4Z6, 04CK4ZZ, 04CL0Z6, 04CL0ZZ, 04CL3Z6, 04CL3ZZ, 04CL4Z6, 04CL4ZZ]
04CM0Z6-04CN4ZZ Extirpation of matter from popliteal artery or bifurcation [right or left, by approach; includes codes 04CM0Z6, 04CM0ZZ, 04CM3Z6, 04CM3ZZ, 04CM4Z6, 04CM4ZZ, 04CN0Z6, 04CN0ZZ, 04CN3Z6, 04CN3ZZ, 04CN4Z6, 04CN4ZZ]
04CP0Z6-04CQ4ZZ Extirpation of matter from anterior tibial artery or bifurcation [right or left, by approach; includes codes 04CP0Z6, 04CP0ZZ, 04CP3Z6, 04CP3ZZ, 04CP4Z6, 04CP4ZZ, 04CQ0Z6, 04CQ0ZZ, 04CQ3Z6, 04CQ3ZZ, 04CQ4Z6, 04CQ4ZZ]
04CR0Z6-04CS4ZZ Extirpation of matter from posterior tibial artery or bifurcation [right or left, by approach; includes codes 04CR0Z6, 04CR0ZZ, 04CR3Z6, 04CR3ZZ, 04CR4Z6, 04CR4ZZ, 04CS0Z6, 04CS0ZZ, 04CS3Z6, 04CS3ZZ, 04CS4Z6, 04CS4ZZ]
04CT0Z6-04CU4ZZ Extirpation of matter from peroneal artery or bifurcation [right or left, by approach; includes codes 04CT0Z6, 04CT0ZZ, 04CT3Z6, 04CT3ZZ, 04CT4Z6, 04CT4ZZ, 04CU0Z6, 04CU0ZZ, 04CU3Z6, 04CU3ZZ, 04CU4Z6, 04CU4ZZ]
04CV0Z6-04CW4ZZ Extirpation of matter from foot artery or bifurcation [right or left, by approach; includes codes 04CV0Z6, 04CV0ZZ, 04CV3Z6, 04CV3ZZ, 04CV4Z6, 04CV4ZZ, 04CW0Z6, 04CW0ZZ, 04CW3Z6, 04CW3ZZ, 04CW4Z6, 04CW4ZZ]
04CY0Z6-04CY4ZZ Extirpation of matter from lower artery or bifurcation [by approach; includes codes 04CY0Z6, 04CY0ZZ, 04CY3Z6, 04CY3ZZ, 04CY4Z6, 04CY4ZZ]
   
ICD-10 Diagnosis  
I70.201-I70.299 Atherosclerosis of native arteries of the extremities
I70.301-I70.799 Atherosclerosis of bypass graft(s) of the extremities
I70.92 Chronic total occlusion of artery of the extremities
I74.3 Embolism and thrombosis of arteries of the lower extremities
I74.5 Embolism and thrombosis of iliac artery
I75.021-I75.029 Atheroembolism of lower extremity
   
Discussion/General Information

Peripheral artery disease (PAD) is an important cause of morbidity that affects up to 10 million people in the United States.  It is caused by the restriction of blood flow to the arms, legs, or internal organs due to partial or total occlusion of the blood vessels.  There are two types of PAD; organic and functional.  Organic PAD, which is the more common form, is due to inflammation and tissue damage in the blood vessels caused by fatty build-up in arteries that blocks normal circulation.  Functional PAD is related to abnormal contractions of the blood vessels due to a disease condition (for example, Raynaud's disease).  This condition may be triggered by smoking, cold temperatures, emotional stress, or working with vibrating machinery. 

PAD affects three major arterial segments of the lower extremity: (1) aorto-iliac arteries, (2) femoro-popliteal (FP) arteries, and (3) infra-popliteal (primarily tibial) arteries.  The disease is usually classified based on claudication (a condition characterized by cramping and pain in the leg due to exercise), resting pain, or degree of tissue loss due to chronic ischemia.  One measure of the presence and severity of PAD in the extremities is the use of the Ankle Brachial Index (ABI).  This test is done by measuring blood pressure at the ankle and in the arms while a person is at rest.  The ABI is expressed as a ratio of the highest blood pressure measurement in the foot divided by the highest blood pressure measurement in the arms.  A normal ABI is usually 1.0 to 1.4, and lower or higher measurements indicate abnormal blood flow in the extremities.  A classification scheme for PAD lesion types has been proposed by the TransAtlantic Inter-Society Consensus (TASC II) working group (Norgren, 2007).  This classification system has been accepted and widely used to assess the severity of PAD through consideration of the location, diameter, and length of occlusions.  There are several different measurement schemes, based on the location of the occlusion.  However, they all rank occlusions from Type A to Type D, with Type A occlusions being the least severe and Type D being the most severe.

More than 70% of individuals diagnosed with PAD remain stable or improve with conservative management.  Those who do not improve may undergo a variety of diagnostic studies which may be used in planning for surgery or percutaneous intervention.  Individuals with critical limb ischemia (CLI), a severe obstruction of the arteries that has progressed to the point of severe pain and even skin ulcers or sores in the extremities, should undergo interventions for revascularization. 

Revascularization procedures used to restore blood flow to the affected limb may involve surgical as well as endovascular approaches.  Surgical bypass procedures involve grafting of a native autologous vein or synthetic graft prosthesis from proximal to the area of the affected artery to distal to the affected area, thus 'bypassing' the occluded portion of the artery.  Due to complications related to bypass surgeries, the use of open and percutaneous endoluminal angioplasty, atherectomy, and stenting have been developed as primary and salvage therapy for PAD.  These types of procedures act to reduce the occlusion by compressing or removing the blockage, as opposed to bypassing it.  

Procedures such as angioplasty, atherectomy, and stenting have been established as standard procedures for the treatment of lower extremity PAD for many decades.  The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) Task Force published their guideline titled, Management of Patients with Peripheral Artery Disease in 2013 (Rooke, 2013).  This document updated its guidance and compiled the recommendations from earlier guidelines in 2005 and 2011. 

The 2013 ACCF/AHA document supports the use of percutaneous or open exposure angioplasty for individuals with claudication and TASC type A lesions.  The document specifically states, "In most claudicant patients being evaluated initially, a 6-month trial of smoking cessation, risk factor modification, exercise, or cilostazol, or a combination, should be initiated before any invasive therapy."

Please refer to Hirsch (2005) for further details on the ACCF/AHA TASC recommendations (see page e517, Figure 8).  The use of these procedures is not supported for more severe lesions. 

In 2015, Jaff and others reported an update of the 2007 TASC II classification.  This publication reiterated support for the existing TASC II classifications for aortoiliac and femoropopliteal segments, and added a new classification for the infrapopliteal segment.  The authors also provided an overview of the current state of evidence addressing various treatment methodologies.  They concluded that, despite the years that have passed since the TASC II publication in 2007, there remains a paucity of trial data comparing open and endovascular approaches for the treatment of CLI or claudication.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Bachoo P, Thorpe PA, Maxwell H, Welch K. Endovascular stents for intermittent claudication. Cochrane Database Syst Rev. 2010;(1):CD003228.
  2. Chowdhury MM, McLain AD, Twine CP. Angioplasty versus bare metal stenting for superficial femoral artery lesions. Cochrane Database Syst Rev. 2014;(6):CD006767.
  3. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol. 2017; 69(11):e71-e126.
  4. Hirsch AT, Haskal ZJ, Hertzer NR, et al.; American Association for Vascular Surgery; Society for Vascular Surgery; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society of Interventional Radiology; ACC/AHA Task Force on Practice Guidelines Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease; American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; Vascular Disease Foundation. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006; 113(11):e463-654.
  5. Jaff MR, White CJ, Hiatt WR, et al.; TASC Steering Committee. An update on methods for revascularization and expansion of the TASC Lesion Classification to include below-the-knee arteries: a supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Endovasc Ther. 2015; 22(5):663-677.
  6. Klein AJ, Jaff MR, Gray BH, et al. SCAI appropriate use criteria for peripheral arterial interventions: an update. Catheter Cardiovasc Interv. 2017 May 10. doi: 10.1002/ccd.27141. [Epub ahead of print]
  7. Norgren L, Hiatt WR, Dormandy JA, et al.; TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007; 45 Suppl S:S5-67.
  8. Rooke TW, Hirsch AT, Misra S, et al.; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society for Vascular Medicine; Society for Vascular Surgery. 2011 ACCF/AHA Focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011; 58(19):2020-2045.
  9. Rooke TW, Hirsch AT, Misra S, et al.; American College of Cardiology Foundation Task Force; American Heart Association Task Force. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013; 61(14):1555-1570.
Index

Angioplasty
Atherectomy
Endarterectomy
Femoropopliteal
Stenting

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.  Updated Coding section with 10/01/2017 ICD-10-PCS procedure code changes.
Revised 11/03/2016 MPTAC review. Updated formatting in the Clinical Indications section. Clarified NM statement regarding individuals with claudication and use of stents or atherectomy devices as salvage. Updated Rationale and References sections.
  10/01/2016 Updated Coding section with 10/01/2016 ICD-10-PCS procedure code changes.
Revised 11/05/2015 MPTAC review. Revised medical necessary statement addressing the use of either percutaneous or open exposure angioplasty to change the requirement of 3 months conservative treatment to 6 months, and added clarification for what comprises conservative treatment. Removed ICD-9 codes from Coding section.
New 08/06/2015 MPTAC review. Initial document development.