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Date Printed: September 1, 2014: 07:24 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2014, 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 2014 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.

02-33000-22

Original Effective Date: 08/15/00

Reviewed: 05/22/14

Revised: 06/15/14

Subject: Endovascular Grafts for Abdominal Aortic Aneurysms

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:

The conventional management of a clinically significant abdominal aortic aneurysm consists of surgical excision with placement of a sutured woven graft. Surgical excision is associated with a perioperative mortality rate of 4%, which may rise to 10% in symptomatic patients. Due to this high mortality rate, endovascular grafts have been investigated as a minimally invasive, catheter-based alternative to open surgical repair of abdominal aortic aneurysms. These devices are deployed across the aneurysm such that the aneurysm is effectively excluded from the circulation with subsequent restoration of normal blood flow.

There are several types of grafts:

In 1999, the U.S. Food and Drug Administration (FDA) approved 2 endovascular grafts for use in the abdominal aorta: the EVT Abdominal Aortic Endovascular Grafting System (Guidant Endovascular Technologies) and the AneuRx® Prosthesis System (now called AneuRx AAAdvantage Stent Graft -Medtronic Vascular, Inc.). In April 2002, FDA approved an additional Guidant device, the Ancure® Aortoiliac System. Several other grafts have been subsequently approved, including the Gore® Excluder® (2002), the Zenith® AAA Endovascular Graft (2003 – now called Zenith Flex AAA Endovascular Graft), the Endologix Powerlink® (2004), the Medtronic Talent® Abdominal Stent Graft System (2008), the Medtronic Vascular Endurant® II AAA Stent Graft System (2010), the Aorfix AAA Flexible Stent Graft System (2013, Lombard Medical, PLC), the OvationAbdominal Stent Graft System (2012, TriVascular, Inc.) and the Zenith® Fenestrated AAA Endovascular Graft (2012).

POSITION STATEMENT:

The use of FDA approved endovascular graft devices for the treatment of abdominal aortic aneurysms meets the definition of medical necessity for ONE of the following indications:

The use of FDA approved endovascular graft devices for the treatment of abdominal aortic aneurysms is considered experimental or investigational for all other indications, including but not limited to:

The use of non-FDA approved endovascular graft devices for the treatment of abdominal aortic aneurysms is considered experimental or investigational.

There is insufficient clinical evidence to permit conclusions on efficacy and net health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used for reporting endovascular grafts for abdominal aortic aneurysm repair:

CPT Coding:

34800

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis

34802

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis

(1 docking limb)

34803

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis

(2 docking limbs)

34804

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using unibody bifurcated prosthesis

34805

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-uniiliac or aorto-unifemoral prosthesis

34808

Endovascular placement of iliac artery occlusion device (list separately in addition to code for primary procedure) (to be used with 34800, 34813, 34825, 34826)

34812

Open femoral artery exposure for delivery of aortic endovascular prosthesis by groin incision, unilateral (use -50 modifier for bilateral procedures)

34813

Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (List separately in addition to code for primary procedure) (used with 34812)

34820

Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (use -50 modifier for bilateral procedures)

34825

Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel

34826

Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; each additional vessel (List separately in addition to code for primary procedure

34841

Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery)

34842

Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

34843

Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

34844

Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

34845

Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery)

34846

Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

34847

Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

34848

Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

75952

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation

75953

Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm, radiological supervision and interpretation

ICD-9 Diagnoses Codes That Support Medical Necessity:

441.3

Abdominal aneurysm, ruptured

441.4

Abdominal aneurysm without mention of rupture

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

l71.3

Abdominal aortic aneurysm, ruptured 

I71.4

Abdominal aortic aneurysm, without rupture

LOINC Codes:

The following information may be required documentation to support medical necessity: Physician history and physical, attending physician progress notes, plan of treatment, and laboratory studies.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Laboratory studies

26436-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

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 revised date

DEFINITIONS:

Abdominal aortic aneurysm: a localized dilatation of the abdominal aorta, typically characterized by pain most prominently in the lumbosacral area and an abnormally prominent abdominal pulsation.

Aorta: the main trunk from which the systemic arterial system proceeds, arising from the left ventricle of the heart, passing upward, then bends over, passing down through the thorax and through the abdomen to about the level of the fourth lumbar vertebra where it divides into the two common iliac arteries.

Endovascular: within the blood vessels.

RELATED GUIDELINES:

Endovascular Stent Grafts for Thoracic Aortic Aneurysms, 02-33000-29

OTHER:

None applicable.

REFERENCES:

  1. Adriaensen ME, Bosch JL, Halpern EF, Myriam Hunink MG, Gazelle GS. Elective endovascular versus open surgical repair of abdominal aortic aneurysms: systematic review of short-term results. Radiology. 09/02; 224(3): 739-47.
  2. Becquemin JP, Pillet JC, et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011 [Epub ahead of print].
  3. Blankensteijn JD, de Jong SE, Prinssen M, van der Ham AC, Buth J, van Sterkenburg SM, Verhagen HJ, Buskens E, Grobbee DE; Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med. 07/09/05; 352(23): 2398-405.
  4. Blue Cross and Blue Shield Association Medical Policy Reference Manual. 7.01.67 Endovascular Grafts for Abdominal Aortic Aneurysms, 04/14.
  5. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC) “Endovascular Repair of Abdominal Aortic Aneurysm TEC Assessments, 2001.
  6. Bosch JL, Kaufman JA, Beinfeld MT, Adriaensen ME, Brewster DC, Gazelle GS. Abdominal aortic aneurysms: cost-effectiveness of elective endovascular and open surgical repair. Radiology. 11/02; 225(2): 337-44.
  7. Cao P, De Rango P, et al. Comparison of surveillance versus aortic endografting for small aneurysm repair (CAESAR): results from a randomized trial. Eur J Vasc Endovasc Surg 2011; 41(1):13-25.
  8. Chaikof EL, Brewster DC, Dalman RL et al. The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50(4):880-96.
  9. Creager MA, Goldstone J, Hirshfeld JW Jr, Kazmers A, Kent KC, Lorell BH, Olin JW, Pauly RR, Rosenfield K, Roubin GS, Sicard GA, White CJ, Merli FG, Rodger GP, Tracy CM, Weitz HH; American College of Cardiology; American Heart Asociation; American College of Physicians Task Force on Clinical Competence; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine and Biology; Society for Vascular surgery. ACC/ACP/SCAI/SVMB/SVS Clinical Competence Statement on vascular medicine and catheter-based peripheral vascular interventions. A report of the American College of Cardiology/American Heart Association/American College of Physicians Task Force on Clinical Competence (ACC/ACP/SCAI/SVMB/SVS Writing Committee to develop a clinical competence statement on peripheral vascular disease). J Am Coll Cardiol. 08/18/04; 44(4): 941-57.
  10. De Bruin JL, Baas AF, et al. Long-term outcomes of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010; 362(20):1881-9.
  11. Dillon M, Cardwell C, Blair PH, Ellis P, Kee F, Harkin DW. Endovascular treatment for ruptured abdominal aortic aneurysm. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD005261. DOI: 10.1002/14651858.CD005261.pub2.
  12. ECRI, Custom Hotline Response. Endovascular Grafts for Prophylactic Abdominal Aortic Aneurysm Repair. (Updated 06/30/05).
  13. Hirsch AT, Haskal ZJ, Hertzer NR, et al, 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 Mar 21;113(11):e463-654.
  14. National Guideline Clearinghouse (NGC). Guideline summary: Endovascular stent-grafts for the treatment of abdominal aortic aneurysms, accessed at guideline.gov 04/28/14.
  15. Ouriel K, Clair DG, et al. Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms. J Vasc Surg 2010; 51(5):1081-7.
  16. Pearce WH, Zarins CK, Bacharach JM, Atherosclerotic Peripheral Vascular Disease Symposium II- Controversies in Abdominal Aortic Aneurysm Repair, Circulation, 2008; 118: 2860-2863.
  17. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, Buskens E, Grobbee DE, Blankensteijn JD; Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 10/14/04; 351(16): 1607-18.
  18. Rooke TW, Hirsch AT, Misra S et al. 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):2020-45.
  19. Ten Bosch JA, Teijink JA, et al. Endovascular aneurysm repair is superior to open surgery for ruptured abdominal aortic aneurysms in EVAR-suitable patients. J Vasc Surg 2010; 52(1):13-8.
  20. U.S. Food and Drug Administration (FDA), New Device Approvals and Clearances, Aorfix Flexible Stent Graft System - P110032, February 2013. Accessed at fda.gov 04/28/14.
  21. U.S. Food and Drug Administration (FDA), New Device Approvals and Clearances, Endurant Stent Graft System - P100021, December 2010. Accessed at fda.gov 04/28/14.
  22. U.S. Food and Drug Administration (FDA), New Device Approvals and Clearances, Zenith® Fenestrated AAA Endovascular Graft (with the adjunctive Zenith Alignment Stent) - P020018/S040, April 2012. Accessed at fda.gov 04/28/14.
  23. U.S. Food and Drug Administration (FDA), New Device Approval, Endologix PowerLink® System- P040002, 10/29/04.
  24. U.S. Food and Drug Administration (FDA), New Device Approval, EXCLUDER™ – P020004, 11/06/02.
  25. U.S. Food and Drug Administration (FDA), New Device Approval, Zenith™ AAA Endovascular Graft, 05/23/03.
  26. United Kingdom EVAR Trial Investigators. Endovascular repair of aortic aneurysm in patients physically ineligible for open repair. N Engl J Med 2010; 362(20):1872-80.
  27. United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysms. N Engl J Med 2010; 362(20):1863-71.
  28. Walker TG, Kalva SP, Yeddula K et al. Clinical practice guidelines for endovascular abdominal aortic aneurysm repair: written by the Standards of Practice Committee for the Society of Interventional Radiology and endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Interventional Radiology Association. J Vasc Interv Radiol 2010; 21(11):1632-55.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/22/14.

GUIDELINE UPDATE INFORMATION:

08/15/00

Medical Coverage Guideline Developed.

01/01/01

HCPCS coding changes.

09/15/02

Reviewed.

01/01/03

HCPCS coding update.

07/15/04

Review and revision of guideline; consisting of updated references and maintaining current coverage.

01/01/05

Annual HCPCS update; consisting of the addition of 34803, 0078T, 0079T, 0080T and 0081T.

07/01/05

3rd quarter HCPCS coding update; consisting of the revision of 0078T.

01/01/06

Annual HCPCS coding update consisting of the revision of 0078T.

03/15/06

Review and revision of guideline consisting of updated references.

08/15/07

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

06/15/09

Biennial review: position statement maintained and references updated.

01/01/10

Annual HCPCS coding update: revised descriptor for codes 34802, and 34803.

10/15/10

Revision; related ICD-10 codes added.

01/01/11

Annual HCPCS coding update. Revised 34900.

05/15/11

Biennial review; position statement, coding section and references updated; formatting changes.

10/01/11

Revision; formatting changes.

01/01/14

Annual HCPCS coding update; added codes 34841-34848; deleted codes 0078T-0081T. Revision; Program Exception section updated.

06/15/14

Review; position statements, description section, coding, & references updated; formatting changes.

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is copyright 2013, 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 2013 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.

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Date Printed: September 1, 2014: 07:24 PM