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Medical Policy Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 161 BCBSA Reference Number: 7.01.178 (For Plan internal use only) NCD/LCD: N/A Related Policies
Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms), #323 Extracranial Carotid Artery Stenting, #219 Stem Cell Therapy for Peripheral Arterial Disease, #348 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Percutaneous revascularization using balloon angioplasty, stent procedures, or atherectomy in individuals with chronic symptomatic lower extremity peripheral arterial disease (see Policy Guidelines) may be considered MEDICALLY NECESSARY when the following criteria are met: • Functionally limiting claudication (see Policy Guidelines); AND • Inadequate response to guideline-directed management and therapy (GDMT), including structured exercise; AND • Potential benefits of revascularization on quality of life, walking performance, and functional status outweigh the risks and durability of the intervention and possible need for repeated procedures (see Practice Guidelines).

Percutaneous revascularization using balloon angioplasty, stent procedures, or atherectomy for treatment of chronic limb-threatening ischemia may be considered MEDICALLY NECESSARY.

Percutaneous revascularization using balloon angioplasty, stent procedures, or atherectomy for treatment of acute limb ischemia may be considered MEDICALLY NECESSARY.

Percutaneous revascularization using balloon angioplasty, stent procedures, or atherectomy in individuals with asymptomatic lower extremity peripheral arterial disease may be considered MEDICALLY NECESSARY if needed for the safety, feasibility, or effectiveness of other invasive, clinically necessary,

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life-saving procedures (e.g., transfemoral aortic valve replacement, mechanical circulatory support, endovascular aortic aneurysm repair).

Percutaneous revascularization using balloon angioplasty, stent procedures, or atherectomy in individuals with asymptomatic lower extremity peripheral arterial disease is considered INVESTIGATIONAL in all other situations.

Percutaneous revascularization using lithotripsy in individuals with lower extremity peripheral arterial disease is considered INVESTIGATIONAL in all situations.

Policy Guidelines Chronic Symptomatic Peripheral Arterial Disease Diagnostic testing for suspected peripheral arterial disease (PAD) requires a multi-faceted approach that incorporates history and physical examination, ankle-brachial index (ABI), and additional physiological testing, as well as noninvasive and potentially invasive (angiography) imaging. Individuals with chronic symptomatic PAD report claudication or other non-joint-related exertional leg symptoms that limit walking performance.

Functional Status Functional status is defined as an individual's ability to meet basic needs, fulfill usual roles, and maintain health and well-being (activities of daily living). Walking ability and performance, and mobility are components of functional status. Treadmill exercise ABI testing can be used to objectively assess functional status and walking performance. Among individuals with chronic symptomatic PAD, this exercise assessment can be used as a baseline measure of functional status and for evaluation of response to therapy.

Structured Exercise Programs for Peripheral Arterial Disease A structured exercise program is an exercise program planned by a qualified health care professional that provides recommendations for exercise training with a goal of improving functional status over time. The program provides individualized recommendations for frequency, intensity, time, and type of exercise. Structured exercise programs are classified as supervised exercise therapy or structured community-based exercise programs. In supervised exercise therapy, training is performed for a minimum of 30 to 45 minutes per 60-minutes session. Supervised sessions are performed at least 3 times per week for a minimum of 12 weeks.

Shared Decision Making Clinical practice guidelines state, "Patient-centered discussions are critical in making appropriate decisions regarding revascularization and for building a trusting longitudinal relationship. More than 70% of patients prefer to have an active role in determining their treatment plan for claudication. Such discussions should be undertaken when considering whether to undergo a revascularization procedure, its timing, and approach for revascularization (ie, endovascular or surgical), and should take into account the patient’s goals, treatment preferences, and perception of risk. Patient engagement is also essential to facilitate smoking cessation, medication adherence, and participation in structured exercise."1,

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required.

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Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes:

Code Description 37254 Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel 37255 Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) 37256 Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel 37257 Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) 37258 Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel 37259 Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure)

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37260 Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel 37261 Revascularization, endovascular, open or percutaneous, iliac vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) 37263 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel 37264 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) 37265 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel 37266 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) 37267 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel 37268 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) 37269 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and

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angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel 37270 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) 37271 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel 37272 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) 37273 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel 37274 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) 37275 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel 37276 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) 37277 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for

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accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel 37278 Revascularization, endovascular, open or percutaneous, femoral and popliteal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) 37280 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel 37281 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) 37282 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel 37283 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, each additional vessel
(List separately in addition to code for primary procedure) 37284 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel 37285 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when performed, within the same artery, unilateral; straightforward lesion, each additional vessel (List
separately in addition to code for primary procedure) 37286 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and

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angioplasty when performed, within the same artery, unilateral; complex
lesion, initial vessel 37287 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement and angioplasty when
performed, within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) lesion, initial vessel 37288 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel 37289 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) 37290 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel 37291 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the atherectomy and angioplasty when performed, within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) 37292 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; straightforward lesion, initial vessel 37293 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) 37294 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including

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transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; complex lesion, initial vessel 37295 Revascularization, endovascular, open or percutaneous, tibial and peroneal vascular territory, with transluminal stent placement, with transluminal atherectomy, including transluminal angioplasty when performed, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the stent placement, atherectomy, and angioplasty when performed, within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) 37296 Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, initial vessel 37297 Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; straightforward lesion, each additional vessel (List separately in addition to code for primary procedure) 37298 Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, initial vessel 37299 Revascularization, endovascular, open or percutaneous, inframalleolar vascular territory, with transluminal angioplasty, including all maneuvers necessary for accessing and selectively catheterizing the artery and crossing the lesion, including all imaging guidance and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, unilateral; complex lesion, each additional vessel (List separately in addition to code for primary procedure) 0505T Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion 0238T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel

HCPCS Codes HCPCS codes:

Code Description C7531 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation C7534 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performed with intravascular ultrasound (initial noncoronary vessel) during diagnostic

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evaluation and/or therapeutic intervention, including radiological supervision and interpretation C7535 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation C9764 Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed C9765 Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed C9766 Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed C9767 Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed C9772 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel (s), when performed C9773 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed C9774 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel (s), when performed C9775 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel (s), when performed

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT/HCPCS codes above if medical necessity criteria are met:

ICD-10 Diagnosis Codes ICD-10-CM diagnosis codes: Code Description I70.201 Unspecified atherosclerosis of native arteries of extremities, right leg I70.202 Unspecified atherosclerosis of native arteries of extremities, left leg I70.203 Unspecified atherosclerosis of native arteries of extremities, bilateral legs I70.208 Unspecified atherosclerosis of native arteries of extremities, other extremity I70.209 Unspecified atherosclerosis of native arteries of extremities, unspecified extremity I70.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg I70.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs I70.218 Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity I70.219 Atherosclerosis of native arteries of extremities with intermittent claudication, unspecified extremity I70.221 Atherosclerosis of native arteries of extremities with rest pain, right leg I70.222 Atherosclerosis of native arteries of extremities with rest pain, left leg I70.223 Atherosclerosis of native arteries of extremities with rest pain, bilateral legs

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I70.228 Atherosclerosis of native arteries of extremities with rest pain, other extremity I70.229 Atherosclerosis of native arteries of extremities with rest pain, unspecified extremity I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower leg I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower leg I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site I70.25 Atherosclerosis of native arteries of other extremities with ulceration I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity I70.269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity I70.291 Other atherosclerosis of native arteries of extremities, right leg I70.292 Other atherosclerosis of native arteries of extremities, left leg I70.293 Other atherosclerosis of native arteries of extremities, bilateral legs I70.298 Other atherosclerosis of native arteries of extremities, other extremity I70.299 Other atherosclerosis of native arteries of extremities, unspecified extremity I70.301 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg I70.302 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, left leg I70.303 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs I70.308 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, other extremity I70.309 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, unspecified extremity I70.311 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, right leg I70.312 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, left leg I70.313 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, bilateral legs I70.318 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, other extremity I70.319 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, unspecified extremity I70.321 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, right leg I70.322 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, left leg I70.323 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, bilateral legs

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I70.328 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, other extremity I70.329 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, unspecified extremity I70.331 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh I70.332 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf I70.333 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of ankle I70.334 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and midfoot I70.335 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of foot I70.338 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg I70.339 Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified site I70.341 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh I70.342 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf I70.343 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of ankle I70.344 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and midfoot I70.345 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot I70.348 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg I70.349 Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site I70.35 Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration I70.361 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, right leg I70.362 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, left leg I70.363 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, bilateral legs I70.368 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, other extremity I70.369 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, unspecified extremity I70.391 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg I70.392 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, left leg I70.393 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs I70.398 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, other extremity I70.399 Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, unspecified extremity I70.401 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, right leg I70.402 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, left leg

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I70.403 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, bilateral legs I70.408 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, other extremity I70.409 Unspecified atherosclerosis of autologous vein bypass graft(s) of the extremities, unspecified extremity I70.411 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, right leg I70.412 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, left leg I70.413 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, bilateral legs I70.418 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, other extremity I70.419 Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, unspecified extremity I70.421 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, right leg I70.422 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, left leg I70.423 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, bilateral legs I70.428 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, other extremity I70.429 Atherosclerosis of autologous vein bypass graft(s) of the extremities with rest pain, unspecified extremity I70.501 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, right leg I70.502 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, left leg I70.503 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, bilateral legs I70.508 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, other extremity I70.509 Unspecified atherosclerosis of nonautologous biological bypass graft(s) of the extremities, unspecified extremity I70.511 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, right leg I70.512 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, left leg I70.513 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, bilateral legs I70.518 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, other extremity I70.519 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with intermittent claudication, unspecified extremity I70.521 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, right leg I70.522 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, left leg I70.523 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, bilateral legs I70.528 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, other extremity

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I70.529 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with rest pain, unspecified extremity I70.531 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh I70.532 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of calf I70.533 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of ankle I70.534 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of heel and midfoot I70.535 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of foot I70.538 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg I70.539 Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of unspecified site I70.541 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh I70.542 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of calf I70.543 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of ankle I70.544 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of heel and midfoot I70.545 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of foot I70.548 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of lower leg I70.549 Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of unspecified site I70.55 Atherosclerosis of nonautologous biological bypass graft(s) of other extremity with ulceration I70.561 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, right leg I70.562 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, left leg I70.563 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, bilateral legs I70.568 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, other extremity I70.569 Atherosclerosis of nonautologous biological bypass graft(s) of the extremities with gangrene, unspecified extremity I70.591 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, right leg I70.592 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, left leg I70.593 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, bilateral legs I70.598 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, other extremity I70.599 Other atherosclerosis of nonautologous biological bypass graft(s) of the extremities, unspecified extremity I70.601 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, right leg I70.602 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, left leg

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I70.603 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, bilateral legs I70.608 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, other extremity I70.609 Unspecified atherosclerosis of nonbiological bypass graft(s) of the extremities, unspecified extremity I70.611 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, right leg I70.612 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, left leg I70.613 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, bilateral legs I70.618 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, other extremity I70.619 Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudication, unspecified extremity I70.621 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, right leg I70.622 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, left leg I70.623 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, bilateral legs I70.628 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, other extremity I70.629 Atherosclerosis of nonbiological bypass graft(s) of the extremities with rest pain, unspecified extremity I70.631 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh I70.632 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of calf I70.633 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of ankle I70.634 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of heel and midfoot I70.635 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot I70.638 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower leg I70.639 Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site I70.641 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh I70.642 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of calf I70.643 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of ankle I70.644 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of heel and midfoot I70.645 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of foot I70.648 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of lower leg I70.649 Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of unspecified site I70.65 Atherosclerosis of nonbiological bypass graft(s) of other extremity with ulceration I70.661 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, right leg I70.662 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, left leg I70.663 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, bilateral legs I70.668 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, other extremity

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I70.669 Atherosclerosis of nonbiological bypass graft(s) of the extremities with gangrene, unspecified extremity I70.691 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, right leg I70.692 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, left leg I70.693 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, bilateral legs I70.698 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, other extremity I70.699 Other atherosclerosis of nonbiological bypass graft(s) of the extremities, unspecified extremity I70.701 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, right leg I70.702 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, left leg I70.703 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, bilateral legs I70.708 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, other extremity I70.709 Unspecified atherosclerosis of other type of bypass graft(s) of the extremities, unspecified extremity I70.711 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, right leg I70.712 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, left leg I70.713 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, bilateral legs I70.718 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, other extremity I70.719 Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudication, unspecified extremity I70.721 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, right leg I70.722 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, left leg I70.723 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, bilateral legs I70.728 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, other extremity I70.729 Atherosclerosis of other type of bypass graft(s) of the extremities with rest pain, unspecified extremity I70.731 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of thigh I70.732 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of calf I70.733 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of ankle I70.734 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of heel and midfoot I70.735 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of foot I70.738 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of lower leg I70.739 Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of unspecified site I70.741 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of thigh I70.742 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of calf I70.743 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of ankle I70.744 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of heel and midfoot I70.745 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of foot I70.748 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of lower leg

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I70.749 Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of unspecified site I70.75 Atherosclerosis of other type of bypass graft(s) of other extremity with ulceration I70.761 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, right leg I70.762 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, left leg I70.763 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, bilateral legs I70.768 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, other extremity I70.769 Atherosclerosis of other type of bypass graft(s) of the extremities with gangrene, unspecified extremity I70.791 Other atherosclerosis of other type of bypass graft(s) of the extremities, right leg I70.792 Other atherosclerosis of other type of bypass graft(s) of the extremities, left leg I70.793 Other atherosclerosis of other type of bypass graft(s) of the extremities, bilateral legs I70.798 Other atherosclerosis of other type of bypass graft(s) of the extremities, other extremity I70.799 Other atherosclerosis of other type of bypass graft(s) of the extremities, unspecified extremity I70.8 Atherosclerosis of other arteries I70.90 Unspecified atherosclerosis I70.91 Generalized atherosclerosis I70.92 Chronic total occlusion of artery of the extremities I73.9 Peripheral vascular disease, unspecified I74.3 Embolism and thrombosis of arteries of the lower extremities I74.4 Embolism and thrombosis of arteries of extremities, unspecified I74.5 Embolism and thrombosis of iliac artery I74.8 Embolism and thrombosis of other arteries I74.9 Embolism and thrombosis of unspecified artery I75.021 Atheroembolism of right lower extremity I75.022 Atheroembolism of left lower extremity I75.023 Atheroembolism of bilateral lower extremities I75.029 Atheroembolism of unspecified lower extremity M62.251 Nontraumatic ischemic infarction of muscle, right thigh M62.252 Nontraumatic ischemic infarction of muscle, left thigh M62.259 Nontraumatic ischemic infarction of muscle, unspecified thigh M62.261 Nontraumatic ischemic infarction of muscle, right lower leg M62.262 Nontraumatic ischemic infarction of muscle, left lower leg M62.269 Nontraumatic ischemic infarction of muscle, unspecified lower leg M62.271 Nontraumatic ischemic infarction of muscle, right ankle and foot M62.272 Nontraumatic ischemic infarction of muscle, left ankle and foot M62.279 Nontraumatic ischemic infarction of muscle, unspecified ankle and foot

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes:

Code Description 37262 Intravascular lithotripsy(ies), iliac vascular territory, including all imaging guidance and radiological supervision and interpretation necessary to perform the intravascular

17

lithotripsy(ies) within the same artery (List separately in addition to code for primary procedure) 37279 Intravascular lithotripsy(ies), femoral and popliteal vascular territory, including all imaging guidance and radiological supervision and interpretation necessary to perform the intravascular lithotripsy(ies) within the same artery (List separately in addition to code for primary procedure)

Description Peripheral Arterial Disease Guidelines recognize 4 clinical subsets of peripheral arterial disease (PAD).1, • Asymptomatic PAD is characterized by reporting of no leg symptoms. Patients with asymptomatic PAD may adapt their activity to avoid leg pain. Those who report no exertional leg symptoms may develop symptoms during an objective walking test. These patients have functional impairment that is comparable to those with claudication. • Chronic symptomatic PAD (claudication) is characterized by exertional leg symptoms that can limit walking and resolve with rest. Typical claudication symptoms may be described as a pain, aching, cramping, or tired/fatigued feeling located in the buttocks, thigh, calf, or foot that occurs consistently during walking, does not start at rest, does not improve during walking, and is usually relieved within approximately 10 minutes of rest. Leg symptom descriptors also include tingling, numbness, burning, throbbing, or shooting. Chronic symptomatic PAD is associated with significant functional (walking) impairment. It is estimated that only one-third of patients with PAD present with symptoms of typical claudication, while most patients with PAD present with other exertional leg symptoms not typical of claudication. All patients with chronic symptomatic PAD, including those with atypical symptoms, have walking impairment. • Chronic limb-threatening ischemia (CLTI) is a severe clinical subset of PAD, associated with ischemic rest pain, nonhealing wounds or ulcers, or gangrene with symptoms present longer than 2 weeks. • Acute limb ischemia is the most severe clinical subset of PAD. It is characterized by a sudden decrease in arterial perfusion of the leg that threatens the viability of the limb. Causes of ALI include embolism, thrombosis within the native artery or at site of previous revascularization (graft or stent), trauma, peripheral aneurysm with distal embolization, or thrombosis. Severity is further classified using the Rutherford classification system (viable, salvageable/marinnally threatened, salvageable/immediately threaten, irreversible.

Prevalence and Risk Factors Patients at risk for PAD are identified based on demographic features, cardiovascular risk factors, or the presence of atherosclerotic vascular disease in other vascular beds. Black race is associated with increased risk for PAD, even after adjustment for conventional risk factors, and is also associated with major adverse cardiovascular events (MACE) and major adverse limb events.

Screening and Diagnosis Clinical assessment, including risk factor assessment, history, physical examination, and consideration of differential diagnoses, is performed before diagnostic testing.2,3,

For individuals at increased risk of PAD, vascular examination with a focus on the lower extremities is recommended. After the history and physical examination identify patients at risk for PAD and with history of physical examination symptoms or signs of PAD, diagnostic testing to establish the diagnosis of PAD is performed. Diagnostic testing for suspected PAD incorporates history and physical examination, ankle- brachial index (ABI), and additional physiological testing, as well as noninvasive and potentially invasive (angiography) imaging.

Measurement of the ankle-brachial index (ABI) is the primary method for establishing the diagnosis of PAD. In patients with history or physical examination findings suggestive of PAD, the resting ABI, with or without

18

ankle pulse volume recordings (PVR) and/or Doppler waveforms, is recommended to establish the diagnosis.

The resting ABI is reported as abnormal (< 0.90), borderline (0.91-0.99), normal (1.00-1.40), or noncompressible (>1.40). In individuals with suspected chronic symptomatic PAD and normal or borderline resting ABI, exercise ABI can be performed.

Treatment Standard treatment for claudication includes medical therapy, foot care, and structured exercise therapy.

Percutaneous revascularization includes catheter-based revascularization procedures using modalities such as percutaneous transluminal (balloon) angioplasty, drug-coated balloon angioplasty, stenting (bare- metal, drug-coated, or covered), and atherectomy.

Revascularization, either percutaneous or surgical, is the standard treatment for CLTI.

Summary Description Revascularization (either surgical or percutaneous) is a treatment option for certain individuals with lower extremity peripheral arterial disease. Percutaneous revascularization procedures include balloon angioplasty, stent procedures, and atherectomy. Lithotripsy is proposed as a vessel preparation option to facilitate definitive endovascular treatment in heavily calcified lesions.

Summary of Evidence For individuals who are adults with symptomatic lower extremity peripheral arterial disease (PAD) who receive percutaneous revascularization with balloon angioplasty, stent procedures, or atherectomy, the evidence includes randomized controlled trials (RCTs), observational studies, and systematic reviews. Relevant outcomes are overall survival, morbid events, functional outcomes, and treatment-related mortality and morbidity. Multiple studies have demonstrated that percutaneous and surgical revascularization for chronic symptomatic PAD can improve symptoms and quality of life in individuals who have not responded to guideline directed medical treatment, including structured exercise. Guidelines recommend that the choice to proceed to revascularization and selection of procedure should be a shared decision-making process, based on clinical presentation, including severity of symptoms and anticipated natural history; degree of functional limitation and quality of life impairment; response to medical therapy, including structured exercise; and the likelihood of a beneficial short- and longer-term outcome, balanced against potential short-term (eg, bleeding, infection, major adverse cardiovascular
events [MACE]), and longer-term procedural risk. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are adults with chronic limb-threatening ischemia (CLTI) who receive percutaneous revascularization with balloon angioplasty, stent procedures, or atherectomy, the evidence includes RCTs, observational studies, and systematic reviews. Relevant outcomes are overall survival, morbid events, functional outcomes, and treatment-related mortality and morbidity. Revascularization is considered the standard treatment for patients with CLTI to minimize tissue loss and preserve a functional limb and ambulatory status. Both endovascular and surgical revascularization have been demonstrated to be effective treatments for preventing amputation in CLTI. In a systematic review of 13 studies of patients with CLTI enrolled in medical and angiogenic therapy trials who did not receive revascularization, a 22% all-cause mortality rate and a 22% rate of major amputation at a median follow-up of 12 months were observed. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are adults with acute limb ischemia who receive percutaneous revascularization with balloon angioplasty, stent procedures, or atherectomy, the evidence includes RCTs, observational studies, and systematic reviews. Relevant outcomes are overall survival, morbid events, functional

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outcomes, and treatment-related mortality and morbidity. A systematic review consisting of RCTS and observational studies demonstrated surgical revascularization is an effective treatment in patients with acute limb ischemia. Thrombolysis was associated with a higher incidence of major vascular events compared to surgical treatment (6.5% vs 4.4%). Both thrombolysis and surgery have comparable limb salvage rates, but thrombolysis carries a higher risk of hemorrhagic complications. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are adults with symptomatic lower extremity PAD who receive percutaneous revascularization using lithotripsy, the evidence includes 1 RCT and nonrandomized studies. Relevant outcomes are overall survival, morbid events, functional outcomes, and treatment-related mortality and morbidity. The RCT demonstrated primary patency at 1 year was superior in the lithotripsy group compared to the control group (80.5% vs 68.0%, P=.017). A major limitation of the study was a lack of comparison to other percutaneous revascularization procedures. The nonrandomized studies are limited by their lack of a control group, small sample sizes, and heterogeneity in clinical and procedural characteristics. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who are adults with asymptomatic lower extremity PAD who receive percutaneous revascularization using any procedure, the evidence includes RCTs, observational studies, and systematic reviews. Relevant outcomes are overall survival, morbid events, functional outcomes, and treatment-related mortality and morbidity. Although some individuals with asymptomatic PAD will progress to symptomatic disease, there is no evidence that performing early invasive revascularization procedures leads to a reduction in the development of symptomatic disease. Further, there is evidence that undergone a revascularization procedure are at increased risk of subsequent complications, including the need for additional subsequent revascularization procedures. Therefore, the risks of the procedure do not outweigh any proposed benefits. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 1/2026 Clarified coding information. 12/2025 Annual policy review. Policy updated with literature review through September 3, 2025; references added. Policy statements unchanged. 3/2025 New medical policy describing medically necessary and investigational indications. Effective 3/1/2025.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

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3. Criqui MH, Matsushita K, Aboyans V, et al. Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association. Circulation. Aug 31 2021; 144(9): e171-e191. PMID 34315230
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