Clinical UM Guideline

 

Subject: Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
Guideline #:  CG-SURG-49 Publish Date:    08/29/2018
Status: Revised Last Review Date:    07/26/2018

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 lesion is TASC type A of the common iliac, external iliac, or superficial femoral arteries, defined as follows:
    1. Common iliac artery: unilateral or bilateral lesions of any length; or
    2. External iliac: unilateral or bilateral lesions less than or equal to 3 cm in length; or
    3. Femoral or popliteal artery: a single stenosis less than or equal to 10 cm in length or a single occlusion less than or equal to 5 cm in length; 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. Criteria above for angioplasty have been met; and
  2. Stenosis or occlusion is present in the common iliac artery, external iliac artery; or
  3. Stenosis or occlusion of intermediate-length (5-15 cm) is present in the femoropopliteal artery.

For individuals with claudication due to aortoiliac occlusive disease (AIOD), the use of covered stent devices is considered medically necessary in the presence of severe calcification or aneurysmal changes where the risk of rupture may be increased after unprotected dilation.

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, or for claudication due to isolated infrapopliteal artery disease.

The use of primary stent placement for the treatment of claudication caused by isolated lesions in the infrapopliteal or tibial arteries is considered not medically necessary.

The use of peripheral vascular angioplasty, with or without stenting, and with or without atherectomy, is considered not medically necessary for treatment of occlusive arterial disease of the deep femoral artery (profunda femoris).

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 or when 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

0505T

Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion

 

 

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.

In 2015 Conte and others representing the Society for Vascular Surgery Lower Extremity Guidelines Writing Group published the Society for Vascular Surgery (SVS) practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication.  In this document they provide the following recommendations:

Recommendations: Interventions for aortoiliac occlusive disease (AIOD) in intermittent claudication (IC):

5.6. We recommend the use of covered stents for treatment of AIOD in the presence of severe calcification or aneurysmal changes where the risk of rupture may be increased after unprotected dilation.

Recommendations: Intervention for femoropopliteal occlusive disease (FPOD) in intermittent claudication (IC):

5.18. For intermediate-length lesions (5-15 cm) in the SFA, we recommend the adjunctive use of self-expanding nitinol stents (with or without paclitaxel) to improve the midterm patency of angioplasty.

5.20. We recommend against EVT of isolated infrapopliteal disease for IC because this treatment is of unproven benefit and possibly harmful.

5.21. We recommend surgical bypass as an initial revascularization strategy for patients with diffuse FP disease, small caliber (<5 mm), or extensive calcification of the SFA, if they have favorable anatomy for bypass (popliteal artery target, good runoff) and have average or low operative risk.

Additionally, this publication by the SVS also states that, “IC rarely results from isolated profunda femoral disease unless there is associated CFA or SFA disease. Endovascular intervention on the profunda femoral artery for claudication symptoms is of unproven value and may carry substantial risk to this most important source of collateral flow in the limb.”

The American College of Cardiology (ACC) and the American Heart Association (AHA) published a joint guideline on the management of patients with lower extremity peripheral artery disease (Gerhard-Herman, 2016).  In this document they provided the following recommendations:

A staged approach to surgical procedures is reasonable in patients with ischemic rest pain (Class IIa Level C-LD)

Definitions

Angioplasty: A catheter-based procedure involving a percutaneous endovascular approach to access an area of vessel stenosis (obstruction). Balloons within the catheter are sequentially inflated, in order to clear the stenosed lesion within the vessel.

Atherectomy: This term refers to a minimally invasive endovascular technique where atherosclerotic plaque is percutaneously removed from the walls of a blood vessel.

Claudication: A condition characterized by pain in the legs. This condition is usually caused by obstruction of the arteries and commonly triggered by exercise. Claudication can be intermittent, usually caused by exercise, or persistent.

Common iliac artery: A large blood vessel originating at the bifurcation of the descending aorta and ending at the bifurcation into the external and internal iliac arteries.

Deep femoral artery (profunda femoris): A branch of the femoral artery that passes closer to the femur than the rest of the femoral artery.

External iliac artery: A branch of the iliac artery that originates at the bifurcation of the common iliac artery and ends where it passes through the pubic tubercle, at which point it is referred to as the femoral artery.

Femoral artery: A major blood vessel in the thigh that originates where the external iliac artery passes through the pubic tubercle.  This vessel gives rise to the deep femoral and superficial femoral arteries.

Popliteal artery: A continuation of the superficial femoral artery, beginning where it passes through the distal portion of the adductor magnus muscle, above the knee joint.

Superficial femoral artery: A continuation of the femoral artery after it gives rise to the deep femoral artery.  It extends to just above the knee, where it is then referred to as the popliteal artery.

Tibial artery: A continuation of the popliteal artery, beginning below the knee, where it bifurcates into the anterior and posterior tibial arteries.

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. Conte MS, Pomposelli FB, Clair DG, et al. Society for Vascular Surgery Lower Extremity Guidelines Writing Group. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg. 2015; 61(3 Suppl):2S-41S.
  4. 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.
  5. 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.
  6. 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.
  7. Klein AJ, Jaff MR, Gray BH, et al. SCAI appropriate use criteria for peripheral arterial interventions: an update. Catheter Cardiovasc Interv. 2017; 90(4):E90-E110.
  8. 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.
  9. 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.
  10. 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

Revised

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified the TASC A lesion definitions in the MN statement regarding treatment of claudication with angioplasty. Changed “femoropopliteal” to “superficial femoral artery” in the MN statement regarding treatment of claudication with angioplasty. Revised the MN statement regarding primary stent placement to clarify the length of intermediate-length stenosis or occlusion to be 5-15 cm. Revised the NMN statement for primary stent placement to clarify the type of lesions addressed. Clarified NMN statement for use of endovascular procedures for CLI. Added Definitions section.

 

07/01/2018

Updated Coding section with 07/01/2018 CPT changes; added CPT 0505T.

Revised

03/22/2018

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Added the use of either percutaneous or open exposure primary stent placement is considered medically necessary for intermediate-length lesions of the femoropopliteal artery. Added new MN statement addressing the use of covered stent devices for claudication due to aortoiliac occlusive disease (AIOD). Added “claudication due to isolated infrapopliteal artery disease” to NMN statement. Updated Discussion and References sections. 

Reviewed

08/03/2017

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.