CMS Diagnostic Abdominal Aortography and Renal Angiography Form

Summary Of Evidence

N/A

Analysis of Evidence

N/A

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

According to the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) High Blood Pressure Clinical Practice Guideline¹, a blood pressure is considered normal for adults with a systolic blood pressure of less than 120 mm Hg and a diastolic blood pressure of less than 80 mm Hg. Hypertension Stage 2, also known as severe hypertension, is noted to be a systolic blood pressure of greater than or equal to 140 mm Hg or a diastolic blood pressure of greater than or equal to 90 mm Hg. Resistant hypertension is uncontrolled high blood pressure despite the use of at least three different antihypertensive medication classes.

Diagnostic arteriography is an invasive procedure for the purpose of evaluating vascular disease. The process involves passing a needle or catheter through the skin under fluoroscopic guidance into an artery followed by injection of contrast material and imaging of the vascular area in question using digital imaging or serial film imaging. The procedures for abdominal aortography or renal arteriography are most commonly done under conscious sedation.

Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, or blood vessels and organs of the body, particularly in arteries, veins, and chambers of the heart. This LCD applies the term angiography when referring to abdominal angiography or renal arteriography.

Covered Indications

1. Medical Necessity for Abdominal Aortography/Angiography
   
   • Acute traumatic abdominal injury
   • Aneurysm and other primary vascular abnormalities
   • Occlusive disease, including evaluation for acute or chronic intestinal ischemia
   • Acute GI hemorrhage
   • Congenital anomaly
   • Prior to arterial interventional procedures or open surgical procedures
2. Medical Necessity for Stand-Alone Renal Angiography
   
   • Severe or difficult to control renal hypertension
     
     • for severe or difficult to control renal hypertension, OR
     • progressive renal insufficiency, OR
     • resistant hypertension
   • Renal neoplasm
   • Hematuria of unknown cause
   • Abnormal kidney imaging involving radioisotopes
   • Renal artery stenosis, aneurysm, trauma, or other intrinsic defects prior to renal arterial intervention
3. Medical Necessity for Lower Extremity or Renal Angiography done at the same time as a different interventional procedure (for example, cardiac catheterization with coronary angiography)
   
   Diagnostic renal angiography or lower extremity angiography performed at the time of an interventional procedure is separately reportable if at least one indication for medical necessity for a stand-alone lower extremity or renal angiography is met AND one of the following are also met:
   
   • No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, OR
   • A prior study is available, but as documented in the medical record:
     
     • The patient’s condition with respect to the clinical indication has changed since the prior study; OR
     • There is inadequate visualization of the anatomy or pathology; OR
     • There is a clinical change during the interventional procedure that requires new evaluation outside the target area of intervention.
4. Medical necessity for a Stand-Alone Lower Extremity Angiography must be documented by pre-procedure clinical assessment. This assessment should include the following:
   
   • Documentation that an invasive intervention is planned, AND
   • Documentation that a prior non-invasive study was completed and indicates further study is needed by angiography for the planned intervention, AND
   • Documentation of one of the following conditions: arterial embolism, acute or chronic ischemia, peripheral vascular disease (includes claudication), or aneurysm.

Limitations

LIMITATIONS FOR ABDOMINAL OR RENAL AORTOGRAPHY/ANGIOGRAPHY OR LOWER EXTREMITY ANGIOGRAPHY:

1. There are no absolute contraindications to diagnostic aortography/angiography. Relative contraindications include but are not limited to:
   
   • Severe hypertension
   • Uncorrectable coagulopathy or thrombocytopenia
   • Clinically significant sensitivity to iodinated contrast material
   • Renal insufficiency based on the estimated glomerular filtration rate (eGFR)
   • Congestive heart failure
   • Certain connective tissue disorders which may indicate increased risk for complications at the puncture site
2. Diagnostic angiography performed at a separate session from an interventional procedure may be separately reportable. If a diagnostic angiogram was performed prior to an interventional procedure, a second diagnostic angiogram performed at the time of an interventional procedure is separately reportable when documentation supports it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. If the prior diagnostic angiogram was performed, a second angiogram (e.g., for the dye injections necessary to perform the interventional procedure) is not separately reportable.
3. The localization or guidance is integral to an interventional procedure and is not separately reportable unless CPT instructions specify otherwise.
4. In addition to the initial procedure, an appropriate frequency of repeat procedures can be allowed as long as medical necessity is clearly established and documented. It is expected that important diagnostic information will be obtained from the angiography, which will assist in patient management and treatment. Repeat angiography may be medically reasonable and necessary if there is documentation of new and incapacitating symptoms.
5. Medicare would not expect to see a high percentage of femoral or iliac angiography done at the same time of coronary studies and such billing could be subject to review.
6. Renal angiography performed at the time of cardiac catheterization in the absence of accepted clinical indication that support medical necessity will be denied as such services are generally not indicated, as mentioned in this LCD.
7. Appropriate non-invasive tests should be performed prior to a repeat angiography. A trial of or a change in medical management would be expected prior to repeat angiography unless the patient is deemed unstable and in need of some type of surgical intervention.

Place of Service (POS)

Angiography services described in this LCD are considered reasonable and necessary when performed in any POS listed below:

• Office 
• Off Campus-Outpatient Hospital 
• Inpatient Hospital 
• On Campus-Outpatient Hospital 
• Emergency Room-Hospital 
• Ambulatory Surgical Center 

Mobile units and all other locations are non-covered.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography, A56682, for applicable CPT codes and diagnosis codes.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.