Anastomosis of Extracranial-Intracranial Arteries Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 09|01|2025 POLICY LAST REVIEWED: 05|21|2025 OVERVIEW This policy documents the coverage criteria for anastomosis of the extracranial-intracranial arteries. In this procedure, the physician anastomoses the arterial and extracranial-intracranial arteries. The physician performs a craniotomy in the affected area and locates the arteries to be anastomosed and dissects them from the surrounding tissue.
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION
Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products Anastomosis of the extracranial-intracranial arteries is covered. COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate section of the Benefit Booklet, Evidence of Coverage or Subscriber Agreement for services not medically necessary.
BACKGROUND Intracranial atherosclerotic disease is the narrowing or obstruction of arteries within the skull that supply the brain. It is caused by atheromatous plaques in the innermost layer of the arterial wall, called the endothelium. Intracranial atherosclerotic disease can lead to transient ischemic attack (TIA), stroke, or death, and is usually diagnosed in patients who have presented with a TIA or stroke. Intracranial atherosclerotic disease is usually treated with anticoagulant therapy (i.e., warfarin) or antiplatelet therapy (e.g., aspirin), together with medication to control risk factors for atherosclerosis.
Extracranial vascular disease refers to atherosclerosis, which is a hardening and narrowing of the walls of these vessels, due to deposits of fats that form plaques within the arteries. As the plaque deposits gradually enlarge, they interfere with blood flow. Atherosclerosis can affect any large-to-medium-sized artery in the body and cause serious health problems. It is especially dangerous in the extracranial arteries that supply the brain, as decreased blood flow to the brain can result in stroke. A minority of subjects with elevated LDL and cholesterol levels will develop clinical disease, and up to 50% of cases of coronary artery disease (CAD) occur in subjects with “normal” levels of total and LDL cholesterol. Thus, there is considerable potential to improve the accuracy of current cardiovascular risk prediction models. A study by the EC/IC Bypass Study Group (1985) failed to confirm the hypothesis that extracranial- intracranial anastomosis is effective in preventing cerebral ischemia in patients with atherosclerotic arterial disease in the carotid and middle cerebral arteries. The premise that this procedure which bypasses narrowed arterial segments improves the blood supply to the brain and reduces the risk of having a stroke has not been demonstrated to be any more effective than no surgical intervention. Accordingly, EC-IC arterial bypass surgery is not considered reasonable and necessary Medical Coverage Policy | Anastomosis of Extracranial-Intracranial Arteries

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

within the meaning of §1862(a)(1) of the Act when it is performed as a treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries.

CODING The following code is covered for Medicare Advantage Plans and Commercial Products: 61711 Anastomosis, arterial, extracranial-intracranial (e.g., middle cerebral/cortical) arteries

RELATED POLICIES Not applicable

PUBLISHED Provider Update, July 2025 Provider Update, April 2024 Provider Update, March 2023 Provider Update, April 2021 Provider Update, May 2020

REFERENCES

1. CMS.Gov Centers for Medicare and Medicaid Services National Coverage Determination (NCD) for Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery (20.2): http://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=54&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d&

2. The EC/IC Bypass Study Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. New England Journal of Medicine; 1985 Nov 7; 313(19):1191-2000. http://www.nejm.org/doi/full/10.1056/NEJM198511073131904

   i

   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS