Anthem Blue Cross Connecticut CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection Form

This document addresses the use of stent grafts placed endovascularly for the treatment of vascular conditions of the aorta including aneurysms, thoracic aortic dissection and traumatic thoracic aortic injury (that is, transection). This document does not address endovascular treatment when limited to the iliac artery alone.

Note: For criteria related to cardiovascular surgery, refer to applicable guidelines used by the plan.

Clinical Indications

Medically Necessary:

The use of U.S. Food and Drug Administration (FDA) approved endovascular/endoluminal stent graft devices is considered medically necessary for individuals with ANY of the following indications:

• Abdominal aortic aneurysm; or
• Aortoiliac aneurysm; or
• Descending thoracic aortic aneurysm; or
• Complicated Type B descending thoracic aortic dissection when distal to the aortic arch; or
• Treatment of traumatic thoracic aortic transection.

The use of a U.S. Food and Drug Administration (FDA) approved fenestrated and branched endovascular/endoluminal stent graft device (including physician-modified endovascular grafts [PMEGs]) is considered medically necessary for repair of juxtarenal and thoraco-abdominal aortic aneurysms when the individual is not a candidate for open surgical repair due to medical comorbidities.

Not Medically Necessary:

The use of non-FDA approved endovascular/endoluminal stent graft devices is considered not medically necessary.

The use of an FDA approved fenestrated and branched endovascular/endoluminal stent graft device (including physician-modified endovascular grafts [PMEGs]) is considered not medically necessary when the criteria above are not met.

The use of endovascular/endoluminal stent graft devices for all other indications not noted above is considered not medically necessary including, but not limited to, the treatment of thoracic aortic arch aneurysms and Type A aortic dissections.