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Date Printed: October 20, 2017: 02:03 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. 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.

02-33000-29

Original Effective Date: 04/15/03

Reviewed: 10/19/16

Revised: 11/15/16

Subject: Endovascular Stent Grafts for Disorders of the Thoracic Aorta

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Rupture of the thoracic aorta is a life-threatening emergency that is nearly always fatal if untreated. Thoracic artery rupture can result from a number of factors. Aneurysms can rupture due to progressive dilatation and pressure of the aortic wall. Rupture can also result from traumatic injury to the aorta, such as occurs with blunt chest trauma. Penetrating injuries that involve the aorta can also lead to rupture. Penetrating ulcers can occur in widespread atherosclerotic disease and lead to aortic rupture.

Aortic dissection can be subdivided into type A, which involves the aortic arch, and type B, which is confined to the descending aorta. Type A dissections are usually treated surgically, while type B dissections are usually treated medically, with surgery indicated for serious complications, such as visceral ischemia, impending rupture, intractable pain, or sudden reduction in aortic size. Dissections associated with obstruction and ischemia can also be subdivided into an obstruction caused by an intimal tear at branch vessel orifices, or by compression of the true lumen by the pressurized false lumen. It has been proposed that endovascular therapy can repair the latter group of dissections by redirecting flow into the true lumen. The success of endovascular stent grafts of abdominal aortic aneurysms has created interest in applying the same technology to the aneurysms and dissections of the descending or thoracoabdominal aorta.There is more controversy regarding the optimal treatment of type B dissections (ie, limited to the descending aorta). In general, chronic, stable type B dissections are managed medically, although some surgeons recommend a more aggressive approach for younger patients in otherwise good health. When serious complications arise from a type B dissection (ie, shock or visceral ischemia), surgical intervention is usually indicated.

Emergent repair of thoracic artery rupture is indicated in many cases in which there is free bleeding into the mediastinum and/or complete transection of the aortic wall. In some cases of aortic rupture, where the aortic media and adventitia are intact, watchful waiting with delayed surgical intervention is a treatment option. With the advent of thoracic endovascular aneurysm repair (TEVAR), the decision making for intervention may be altered, as there may be a greater tendency to intervene in borderline cases due to the potential for fewer adverse events with TEVAR.

Thoracic endovascular aneurysm repair (TEVAR) involves the percutaneous placement of a stent graft in the descending thoracic or thoracoabdominal aorta. It is a less invasive alternative than open surgery for the treatment of thoracic aortic aneurysms, dissections, or rupture, and thus has the potential to reduce the morbidity and mortality of open surgery. Endovascular stenting may also be an alternative treatment to medical therapy for thoracic aortic aneurysms or thoracic aorta dissections There are several endovascular grafts on the market approveded by the U.S. Food and Drug Administration (FDA) for use in thoracic endovascular aneurysm repair.

POSITION STATEMENT:

Endovascular stent grafts meet the definition of medical necessity for the treatment of descending thoracic aortic aneurysms without dissection using devices approved by the U.S. Food and Drug Administration (FDA) for their approved specifications.

Endovascular stent grafts using devices approved by FDA meet the definition of medical necessity in the following situation:

Treatment of acute, complicated (organ or limb ischemia or rupture) type B thoracic aortic dissection.

Endovascular stent grafts meet the definition of medical necessity for the treatment of rupture of the descending thoracic aorta.

Endovascular stent grafts are considered experimental or investigational for the treatment of thoracic aortic lesions that do not meet the above criteria, including but not limited to thoracic aortic arch aneurysms. The evidence is insufficient to determine the effects of the technology on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

33880

Endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin

33881

Endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin

33883

Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); initial extension

33884

Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); each additional proximal extension (List separately in addition to code for primary procedure)

33886

Placement of distal extension prosthesis(s) delayed after endovascular repair of descending thoracic aorta

33889

Open subclavian to carotid artery transposition performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision, unilateral

75956

Endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation

75957

Endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation

75958

Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption), radiological supervision and interpretation

75959

Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic aorta, as needed to level of celiac origin, radiological supervision and interpretation

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Endovascular Grafts for Abdominal Aortic Aneurysm, 02-33000-22

OTHER:

None Applicable

REFERENCES:

  1. Biancari F, Mariscalco G, Mariani S, et al. Endovascular treatment of degenerative aneurysms involving only the descending thoracic aorta: systematic review and meta-analysis. J Endovasc Ther. Apr 2016;23(2):387-392.
  2. Blue Cross and Blue Shield Association, Medical Policy Reference Manual, 7.01.86 Endovascular Stent Grafts for Disorders of the Thoracic Aorta, 05/16.
  3. ECRI, HTAIS Hotline Service Custom Reports. Endovascular Grafts for Thoracic Aortic Aneurysms (Updated 03/31/05).
  4. Grabenwoger M, Alfonso F, Bachet J, et al. Thoracic Endovascular Aortic Repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. May 4 2012;33(13):1558-1563.
  5. Hayes, Inc. HAYES Medical Technology Directory. Endovascular Repair of The Thoracic Aorta Lansdale, PA: Hayes, Inc Aug 2004. Update performed Aug 2005.
  6. Hayes, Inc. HAYES Medical Technology Directory. Endovascular Repair of Thoracic Aortic Aneurysms and Dissections. Lansdale, PA: Hayes, Inc.; Feb 2007.
  7. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease: Executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol. 2010 Apr 6;55(14): e27-e129.
  8. Makaroun MS, Dillavou ED, Kee ST, Sicard G, Chaikof E, Bavaria J, Williams D, Cambria RP, Mitchell RS. Endovascular treatment of thoracic aortic aneurysms: results of the phase II multicenter trial of the GORE TAG thoracic endoprosthesis. J Vasc Surg. 01/05; 41(1): 1-9.
  9. National Institute for Clinical Excellence (NICE). A systematic review of the recent evidence for the efficacy and safety relating to the use of endovascular stent-graft (ESG) placement in the treatment of thoracic aortic disease. 04/05.
  10. U.S. Food and Drug Administration (FDA), Center for Devices and Radiologic Health. Summary of Safety and Effectiveness Data, GORE TAG Thoracic Endoprosthesis. PMA # P040043. 03/23/05.
  11. U.S. Food and Drug Administration (FDA), Center for Devices and Radiologic Health. Summary of Safety and Effectiveness Data, Relay Thoracic Stent-Graft with Plus Delivery System, 2012; accessed at accessdata.fda.gov 09/20/16.
  12. U.S. Food and Drug Administration (FDA), Center for Devices and Radiologic Health. Summary of Safety and Effectiveness Data, Valiant Thoracic Stent Graft with the Captivia Delivery System, 2012; accessed at accessdata.fda.gov 09/20/16.
  13. U.S. Food and Drug Administration (FDA), New Device Approval, Zenith® TX2® Thoracic TAA Endovascular Graft, 05/08.
  14. Veith FJ, Abbott WM, Yao JS, Goldstone J, White RA, Abel D, Dake MD, Ernst CB, Fogarty TJ, Johnston KW, Moore WS, van Breda A, Sopko G, Didisheim P, Rutherford RB, Katzen BT, Miller DC; Endovascular Graft Committee, an Ad Hoc Conjoint Committee of the Joint Council of the Society for Vascular Surgery and International Society for Cardiovascular Surgery and Society of Interventional Radiology. Guidelines for development and use of transluminally placed endovascular prosthetic grafts in the arterial system. J Vasc Interv Radiol. 2003 Sep; 14(9 Pt 2): S405-17.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/27/16.

GUIDELINE UPDATE INFORMATION:

04/15/03

New Medical Coverage Guideline.

04/15/04

Review and revision to guideline; consisting of updated references and no change to investigational status.

04/15/05

Review and revision to guideline; consisting of updated references.

05/15/05

Revision to guideline; consisting of formatting changes.

01/01/06

Annual HCPCS coding update consisting of the deletion of 0033T – 0040T and the addition of 33880 – 33891 and 75956 – 75959.

03/15/06

Review and revision of guideline consisting of updated references and addition of coverage criteria.

08/15/07

Review and revision of guideline consisting of updated references and reformatted guideline.

06/15/09

Biennial review: position statement maintained, description section and updated references.

05/15/11

Biennial review: position statement and references updated.

05/11/14

Revision: Program Exceptions section updated.

11/15/16

Revision; title, description, position statement, coding, and references updated.

Date Printed: October 20, 2017: 02:03 PM