This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to persons covered by the Mississippi Children's Health Insurance Program, Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Endovascular Stent Grafts for Thoracic Aortic Aneurysms

Endovascular Stent Grafts for Thoracic Aortic Aneurysms

 

DESCRIPTION

 The traditional standard therapy for thoracic aortic aneurysm (TAA) is open operative repair with graft replacement of the diseased segment. This procedure requires lateral thoracotomy, use of cardiopulmonary bypass, long operation times, and a variety of peri- and postoperative complications, with spinal cord ischemia considered the most devastating. 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 thorabdominal aorta.

In March 2005, the GORE-TAG Thoracic Endoprosthesis was approved by the U.S. Food and Drug Administration (FDA) for endovascular repair of aneurysms of the descending thoracic aorta. Use of this device requires patients have adequate iliac/femoral access; aortic inner diameter in the range of 23-37 mm; and 2 cm non-aneurysmal aorta proximal and distal to the aneurysm.

In May 2008, the Zenith TX2® TAA Endovascular Graft” (Cook Incorporated, Bloomington, IN) was approved by the FDA through the PMA process for the endovascular treatment of patients with aneurysms or ulcers of the descending thoracic aorta. Indicated aortic inner diameter is in the range of 24-38 mm.

In June 2008, the Talent™ Thoracic Stent Graft System (Medtronic Vascular, Santa Rosa, CA) was approved by the FDA through the PMA process for the endovascular repair of fusiform and saccular aneurysms/penetrating ulcers of the descending thoracic aorta. Indicated aortic inner diameter is in the range of 18 - 42mm.

 

POLICY

 Endovascular stent grafts using devices approved by the U.S. Food and Drug Administration may also be considered medically necessary in the following situations:
  • Treatment of descending thoracic aortic aneurysms without dissection (see Policy Guidelines);
  • Treatment of acute, complicated (organ or limb ischemia or rupture) Type B thoracic aortic dissection.

Endovascular stent grafts are considered investigational for the treatment of thoracic aortic arch aneurysms.

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

 Endograft placement relies on non-aneurysmal aortic segments proximal and distal to the aneurysm and/or dissection for anchoring, and a maximal graft diameter that varies by device.
  • The GORE TAG® endoprosthesis is approved by the U.S. Food and Drug Administration (FDA) for “>2 cm non-aneurysmal aorta proximal and distal to the aneurysm and an “aortic inner diameter of 23–37 mm.”
  • The Talent™ Thoracic Stent Graft System is approved by the FDA for “non-aneurysmal aortic proximal and distal neck lengths >20mm” and “non-aneurysmal aortic diameter in the range of 18–42 mm.”
  • The Zenith 2X2® device is approved by the FDA for non-aneurysmal aortic segments “of at least 25 mm in length” and “diameter measured outer wall to outer wall of no greater than 38 mm and no less than 24 mm.”

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

 7/2003: Approved by Medical Policy Advisory Committee (MPAC)

4/20/2005: Hyperlink to Endovascular Grafts for Abdominal Aortic Aneurysms deleted

3/23/2006: Coding updated. CPT4 2006 revisions added to policy

5/18/2006: Policy revised. Revisions approved by Medical Policy Advisory Committee (MPAC)

6/22/2006: Code reference section updated, all CPT codes moved from non-covered table to covered table. CPT code 33891 added to covered table. ICD-9 procedure code 39.73 added to covered table.

8/19/2009: Policy reviewed, no changes

05/09/2011: Policy description revised to add additional FDA-approved devices: Zenith 2X2® device and Talent™ Thoracic Stent Graft System.  The first policy statement was revised to indicate that endovascular stent grafts may be considered medically necessary for the treatment of descending thoracic aortic aneurysms using devices approved by the U.S. Food and Drug Administration for their approved specifications.  The approved specifications for each device were added to the Policy Guidelines section.

09/23/2011:  Policy statement revised to indicate that thoracic endovascular aneurysm repair may be considered medically necessary for complicated Type B dissections.  

09/25/2012: Policy reviewed; no changes.

 

SOURCE(S)

Blue Cross Blue Shield Association policy # 7.01.86

Hayes Medical Technology Directory

 

CODE REFERENCE

 This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Code Number

Description

CPT-4

33880Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthethesis, plus descending thoracic aortic extension(s), if required, to level of celiac artery origin
33881Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthethesis, plus descending thoracic aortic extension(s), if required, to level of celiac artery origin
33883Placement of proximal prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); initial extension
33884Placement of proximal prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); each additional proximal extension  (list separately in addition to code for primary procedure)
33886Placement of distal extension prosthesis(s) delayed after endovascular repair of descending thoracic aorta
33889Open subclavian to carotid artery transposition performed in conjunction with endovascular repair of desending thoracic aorta, by neck incision, unilateral
33891Bypass graft, with other than vein, transcervical retropharyngeal carotid-carotid, performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision 
75956Endovascular repair of descending thoracic aorta (eg, 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
75957Endovascular repair of descending thoracic aorta (eg, 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
75958Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption), radiological supervision and interpretation  
75959Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic aorta, as needed, to level of celiac origin, radiological supervision and interpretation

ICD-9 Procedure

 39.73Endovascular implantation of graft in thoracic aorta 

ICD-9 Diagnosis

441.1

Thoracic aneurysm, ruptured

441.2

Thoracic aneurysm without mention of rupture

441.6

Thoracoabdominal aneurysm, ruptured

441.7

Thoracoabdominal aneurysm without mention of rupture

HCPCS

  

 

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