Anthem Blue Cross Connecticut CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone Form

This document addresses venous angioplasty with or without stent placement, or venous stenting alone, as a treatment modality for a variety of conditions, including, but not limited to: venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, and as a method to improve venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).

Note: Angiographic evaluation and endovascular intervention for dialysis access circuit dysfunction is not addressed in this document. For more information, please refer to:

• CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction
• CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

Clinical Indications

Medically Necessary:

Venous angioplasty with or without stent placement or venous stenting alone is considered medically necessary for treatment of the following conditions:

1. Venous thoracic outlet syndrome; or
2. Thrombotic obstruction of major hepatic veins (Budd-Chiari syndrome); or
3. Superior vena cava syndrome; or
4. Iliac vein compression syndrome (for example, May-Thurner Syndrome); or
5. Pulmonary vein stenosis; or
6. Congenital heart disease including, but not limited to:
   1. Stenosis or hypoplasia of a pulmonary artery in a child; or
   2. Symptomatic stenosis/occlusion of superior or inferior vena cava; or
   3. Venous narrowing due to repair of sinus venosus atrial septal defect (ASD); or
   4. Venous obstruction of an atrial baffle following Mustard or Senning repair of transposition of the great arteries;
      or
7. Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, when the following criteria are met:
   1. Documented IIH diagnosis; and
   2. Either of the following:
      1. Presence of bilateral venous sinus stenosis, or
      2. Unilateral stenosis and contralateral hypoplasia;
         and
   3. Individual has refractory disease or is intolerant to maximum medical therapy.

Not Medically Necessary:

Venous angioplasty with or without stent placement or venous stenting alone is considered not medically necessary for the treatment of all other conditions not listed above including, but not limited to:

1. Multiple sclerosis; or
2. Chronically occluded iliac veins; or
3. Ilio-femoral venous thrombosis; or
4. Nutcracker syndrome.