Endovascular Therapy for Intracranial Aneurysms

POLICY NUMBER

L.7.01.402

DESCRIPTION

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.

Aneurysms of the intracranial circulation are serious and potentially life-threatening disorders. An aneurysm is a weakness in the wall of an artery, probably caused by a combination of congenital defects in the vascular wall and degenerative changes that causes bulging and may lead to rupture. One type of aneurysm is formed as a bulge out from the artery wall, creating a pouch-like projection referred to as a saccular aneurysm. The narrow portion of a saccular aneurysm where it joins the parent vessel is called the neck, and the rounded bulge is known as the dome. Fusiform aneurysms, the other major anatomical type of aneurysm, involve circumferential enlargement of a portion of the vessel wall. The bulging of an unruptured intracranial aneurysm may cause symptoms such as headache, vomiting, and alteration in level of consciousness. Rupture of an intracranial aneurysm beneath the arachnoid membrane leads to bleeding into the brain, known as subarachnoid hemorrhage (SAH). This produces brain damage and ischemia, severe motor and sensory loss, and, in some patients, progresses to coma and death (Chung and Caplan, 1999). Treatment of unruptured intracranial aneurysms presents many difficult choices for physicians and patients since the natural history of unruptured aneurysms is not encouraging, yet there are serious adverse outcomes associated with both surgical and endovascular treatment (Hadjivassiliou et al., 2001).

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 patients diagnosed with an intracranial aneurysm and a history of subarachnoid hemorrhage (SAH).

POLICY

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 medicallynecessary.

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.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

8/2002: Approved by Medical Policy Advisory Committee (MPAC)

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. Code description revised for ICD9 procedure code 39.72.

08/28/2015: Code Reference section updated for ICD-10.

06/01/2016: Policy number L.7.01.402 added. Policy Guidelines updated to add medically necessary and investigative definitions.

09/24/2019: Code Reference section updated to add new ICD-10 procedure code 03VG3HZ, effective 10/01/2019.

10/17/2023: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

08/20/2024: Policy reviewed; no changes.

SOURCE(S)

Hayes Medical Technology Directory

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

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

Covered Codes

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