Anthem Blue Cross Connecticut CG-SURG-93 Angiographic Evaluation and Endovascular Intervention for Dialysis Access Circuit Dysfunction Form

This document addresses angiographic evaluation for dialysis access circuit dysfunction and treatment for stenotic or thrombosed arterio-venous grafts (AVG) or fistulas (AVF). This document does not address angiographic evaluation as a treatment for venous thoracic outlet syndrome, superior vena cava syndrome, Budd-Chiari syndrome, congenital cardiac defects, lower extremity venous congestion, or improving venous flow in individuals with multiple sclerosis and chronic cerebrospinal venous insufficiency (CCSVI).

Note: Please see the following related document for additional information:

• CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

Clinical Indications

Medically Necessary:

1. Angiographic evaluation for arterio-venous graft (AVG) or arterio-venous fistula (AVF) dysfunction is considered medically necessary when either of the following abnormalities are present and persistent (1 or 2):
   1. Abnormalities of clinical monitoring suggestive of stenosis or thrombosis; or
   2. Significant changes in access blood flow or pressures:
      For AVG:
      1. Intragraft blood flow less than 600 mL/min; or
      2. Venous segment static pressure ratio greater than 0.5; or
      3. Arterial segment static pressure ratio greater than 0.75; or

For AVF:

1. Access flow rate less than 500 mL/min; or
2. Venous segment static pressure ratio greater than 0.5.

2. Endovascular intervention (with or without stent placement) is considered medically necessary as a treatment for stenotic or thrombosed AVG or AVF when the following criteria are met (1, 2 or 3):
   1. Stenosis without thrombosis when (a and b) are met:
      1. Hemodynamically significant stenosis (for example, a greater than 50% reduction in normal vessel); and
      2. Stenosis is associated with any of the clinical or physiological abnormalities noted above; or
   2. Stenosis is associated with thrombosis; or
   3. Thrombosis.

Note: Examples of abnormalities of clinical monitoring suggestive of stenosis or thrombosis may include; abnormal physical findings, such as persistent arm swelling, collateral veins, and altered features of the pulse or thrill, edema in the extremity distal to the graft or fistula; problems noted during the dialysis session, such as difficulty with cannulation, aspiration of clots, inability to achieve the target dialysis blood flow, or prolonged bleeding from the needle puncture sites, an unexplained decrease in the delivered dialysis dose [Kt/V] on a constant hemodialysis prescription or an AVF that has failed to mature.

Not Medically Necessary:

Angiographic evaluation for AVF or AVG dysfunction is considered not medically necessary when the above criteria are not met and for all other indications.

Endovascular intervention is considered not medically necessary when the above criteria are not met and for all other indications.