![]() | Clinical UM Guideline |
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Description |
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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 |
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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:
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:
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:
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 |
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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 | |
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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 |
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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 |
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Government Agency, Medical Society, and Other Authoritative Publications:
Index |
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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 |
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Status |
Date |
Action |
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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. |