Anthem Blue Cross Connecticut Commercial Clinical Policy

Anthem Blue Cross Connecticut CG-SURG-59 Vena Cava Filters Form



Vena Cava Filter Placement

Indications

(653114) Does the patient have a confirmed acute venous thromboembolism (pulmonary embolism or proximal deep vein thrombosis)? 
(653115) Does the patient have a documented contraindication to anticoagulation therapy due to active bleeding or severe bleeding diathesis? 
(653116) Has the patient had recent major surgery in the past 30 days? 
(653117) Does the patient have severe thrombocytopenia with platelet count less than 50,000/mm3? 
(653118) Does the patient have a history of intracranial bleeding? 
(653119) Does the patient have a history of active major bleeding when anticoagulated within therapeutic range? 
(653120) Has the patient had documented failure to respond to therapeutic-level anticoagulation therapy? 
(653121) Does the patient have poor cardiopulmonary reserve or chronic thromboembolic pulmonary hypertension? 

Vena Cava Filter Retrieval

Indications

(653122) Does the indication for the vena cava filter no longer exist? 
(653123) Is the indication for the vena cava filter time-limited (e.g., short-term contraindication to anticoagulation therapy)? 
(653124) Has the patient experienced filter-related adverse events or complications such as filter fracture, filter occlusion, or pulmonary embolism due to the device? 

Prophylactic Use of Vena Cava Filter


Contraindications

(653125) Is the use of the vena cava filter intended for prevention of venous thromboembolism in individuals undergoing bariatric surgery? 
(653126) Is the individual suffering from severe trauma without documented venous thromboembolism? 
(653127) Does the patient have cancer and recurrent venous thromboembolism, despite anticoagulation treatment? 

Vena Cava Filter as an Adjunct to Anticoagulation Therapy

Notes: Use of a vena cava filter as an adjunct to anticoagulation therapy is considered not medically necessary.


Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



This document addresses the clinical use of vena cava filters (inferior vena cava [IVC] filters and superior vena cava filters) in the management of acute venous thromboembolism (pulmonary embolism [PE] and deep venous thrombosis [DVT]).

Clinical Indications

Medically Necessary:

  1. Vena cava filter placement is considered medically necessary for either of the following indications:
    1. Individual has a confirmed acute venous thromboembolism (pulmonary embolism [PE] or proximal deep vein thrombosis [DVT]) and a documented contraindication to anticoagulation therapy, including but not limited to any of the following:
      1. Active bleeding or severe bleeding diathesis (hypocoagulopathy); or
      2. Recent major surgery in the past 30 days; or
      3. Severe thrombocytopenia (that is, platelet count less than 50,000/mm3 [50 x 109/L]); or
      4. History of intracranial bleeding; or
      5. History of active major bleeding when anticoagulated within therapeutic range; or
    2. Individual has a confirmed acute venous thromboembolism (PE or proximal DVT) and any of the following:
      1. Individual has a documented failure to respond to therapeutic-level anticoagulation therapy (for example, history of development of pulmonary embolism or recurrent deep venous thrombosis while on therapeutic-level anticoagulation therapy); or
      2. Individual has poor cardiopulmonary reserve or chronic thromboembolic pulmonary hypertension.
  2. Retrieval (removal) of a vena cava filter is considered medically necessary when any of the following criteria are met:
    1. The indication for the vena cava filter no longer exists; or
    2. The indication for the vena cava filter is time-limited (for example, a short-term contraindication to anticoagulation therapy); or
    3. The individual has a filter-related adverse event or complications (such as filter fracture, filter occlusion, or pulmonary embolism due to the device).

Not Medically Necessary:

  1. Prophylactic use of a vena cava filter is considered not medically necessary if the above criteria are not met and for all other conditions including, but not limited to:
    1. Prevention of venous thromboembolism in individuals undergoing bariatric surgery; or
    2. Severe trauma without documented venous thromboembolism; or
    3. Cancer and recurrent venous thromboembolism, despite anticoagulation treatment.
  2. Use of a vena cava filter as an adjunct to anticoagulation therapy is considered not medically necessary.