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

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.