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Endovascular occlusion therapy using electrolytically detachable coils and/or stents is intended as an alternative to surgical treatment for patients diagnosed with an unruptured or ruptured intracranial aneurysm or pseudoaneurysm. The objective of this therapy is to occlude blood flow to the vascular lesion by using implantable endovascular coils and/or stents that are percutaneously deployed within the aneurysm.

Pseudoaneurysms of the cerebral circulation are bulging or dissected arterial segments. They are most often the result of trauma, either accidental or surgical. Pseudoaneurysms have also been associated with arteriovenous malformations of the intracranial vessels (Garcia-Monaco et al., 1993). Historically they have been treated with surgical excision in much the same way as true intracranial aneurysms.

Endovascular occlusion therapy using electrolytically detachable coils and stents has been developed as an alternative to surgical treatment for patients diagnosed with intracranial aneurysms and pseudoaneurysms. They are particularly valuable for patients who are not candidates for open surgical treatment. One endovascular coil is approved by the Food and Drug Administration (FDA) specifically for treatment of intracranial aneurysms. The Guglielmi Detachable Coil (GDC) System (Boston Scientific/Target, Fremont, CA) is approved for embolization of certain intracranial aneurysms that, because or their morphology, their location, or the patient’s general medical condition, are considered by the treating neurosurgical team to be very high risk for management using traditional operative techniques, or inoperable.

Definitive patient selection criteria for endovascular therapy for intracranial aneurysms and pseudoaneurysms have not been established. However, GDC embolization may provide a safe and effective alternative to traditional craniotomy for patients whose aneurysms are otherwise untreatable due to their location in the posterior circulation or other areas of the brain that are inaccessible to surgery or for patients who are not suitable candidates for surgery due to comorbidity. Patients with saccular aneurysms that demonstrate a dome:neck ratio of 2.0 or greater are most likely to benefit from endovascular treatment. A recent study has shown that basilar artery trunk aneurysms, in which the anatomy of the brain severely limits attempts at surgical clipping, may be safely and effectively treated with endovascular coils. Therapeutic intervention should be considered most seriously for patientsdiagnosed with an intracranial aneurysm and a history of subarachnoid hemorrhage (SAH).

The use of endovascular therapy for saccular intracranial aneurysms of the posterior cerebral circulation and other intracranial aneurysms whose surgical ligation and clipping would pose great technical difficulty or be medically contraindicated is considered medically necessary.

The use of endovascular therapy for intracranial aneurysms or pseudoaneurysms whose location and morphology would allow for relatively simple surgical ligation and clipping is considered investigational.

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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.

11/5/2003: Code Reference section completed

10/16/2006: Policy reviewed, no changes

9/30/2009: Code reference section updated. New ICD9 procedure codes 39.75 and 39.76 added to covered table. 

Hayes Medical Technology Directory

Covered Codes

*Some covered procedure codes have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section.

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