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Medical Policy Endovascular Stent Grafts for Abdominal Aortic Aneurysms Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 098

BCBSA Reference Number: 7.01.67 (For Plan internal use only) NCD/LCD: NA Related Policies
Endovascular Stent Grafts for Disorders of the Thoracic Aorta, #233 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

The use of endoprostheses approved by the FDA as a treatment of abdominal aortic aneurysms (AAAs) may be MEDICALLY NECESSARY as a treatment of AAAs in any of the following clinical situations: • An aneurysmal diameter greater than 5.0 cm, • An aneurysmal diameter of 4–5.0 cm that has increased in size by 0.5 cm in the last 6 months,
• An aneurysmal diameter that measures twice the size of the normal infrarenal aorta, or • A ruptured abdominal aortic aneurysm.

The use of endoprostheses approved by the FDA as a treatment of AAAs is INVESTIGATIONAL when the above criteria are not met, including but not limited to the following clinical situations: • Treatment of smaller aneurysms that do not meet the current recommended threshold for surgery • Treatment of aneurysms that do meet the recommended threshold for surgery in patients who are ineligible for open repair due to physical limitations or other factors.

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) This procedure is performed in the inpatient setting.

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Commercial PPO and Indemnity This procedure is performed in the inpatient setting. Medicare HMO BlueSM This procedure is performed in the inpatient setting. Medicare PPO BlueSM This procedure is performed in the inpatient setting. 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 34701 Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) 34702 Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) 34703 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) 34704 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) 34705 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of

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the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) 34706 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) 34707 Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation) 34708 Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, traumatic disruption) 34709 Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated (List separately in addition to code for primary procedure) 34710 Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; initial vessel treated 34711 Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; each additional vessel treated (List separately in addition to code for primary procedure) 34841 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) 34842 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34843 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and

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interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34844 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34845 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) 34846 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34847 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 34848 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) ICD-10 Procedure Codes ICD-10-PCS procedure codes: Code Description 04V03DZ Restriction of Abdominal Aorta with Intraluminal Device, Percutaneous Approach 04U04JZ Supplement Abdominal Aorta with Synthetic Substitute, Percutaneous Endoscopic Approach 04U03JZ Supplement Abdominal Aorta with Synthetic Substitute, Percutaneous Approach 04V04DZ Restriction of Abdominal Aorta with Intraluminal Device, Percutaneous Endoscopic Approach

Description Management of a clinically significant abdominal aortic aneurysm (AAA) consists of surgical excision with the placement of a sutured woven graft or endovascular grafting.1, Surgical excision is associated with a perioperative mortality rate between 1% and 5%. Perioperative morbidity and mortality are highest in older female patients with cardiac, pulmonary, or kidney disease; the most common cause of death is multisystem organ failure. Due to the high mortality rate, endovascular prostheses were developed as a less risky and minimally invasive, catheter-based alternative to open surgical excision of AAAs. These devices are deployed across the aneurysm such that the aneurysm is effectively “excluded” from the circulation, with subsequent restoration of normal blood flow.

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The main potential advantage of endovascular grafts for an AAA is that they offer a less invasive and less risky approach to the repair of abdominal aneurysms. While the use of an endovascular approach has the potential to reduce the relatively high perioperative morbidity and mortality associated with open AAA repair, use of endovascular grafts also has potential disadvantages. In particular, there are concerns about the durability of the anchoring system, aneurysm expansion, and other late complications related to the prosthetic graft. Aneurysm expansion may result from perivascular leaks, also known as endoleaks, which are a unique complication of endoprostheses. Perivascular leaks may result from an incompetent seal at one of the graft attachment sites, blood flow in aneurysm tributaries (these tributaries are ligated during open surgery), or perforation of graft fabric.2,3,4,5, Several types of grafts are currently in use: straight grafts, in which both ends are anchored to the infrarenal aorta, and bifurcated grafts, in which the proximal end is anchored to the infrarenal aorta, and the distal ends are anchored to the iliac arteries. Fenestrated grafts have also been investigated. These grafts are designed with openings in the wall that can be placed across the renal or celiac arteries while still protecting vessel patency through these critical arteries. Also, extensions can be placed from inside the main endograft body into the visceral arteries to create a hemostatic seal.

Summary Endovascular stent grafts can be used as minimally invasive alternatives to open surgical repair for treatment of abdominal aortic aneurysms (AAAs). Open surgical repair of AAAs has high morbidity and mortality, and endovascular grafts have the potential to reduce the operative risk associated with AAA repair. For individuals who have abdominal aortic aneurysms (AAAs) eligible for open repair who receive endovascular stent grafts, the evidence includes randomized controlled trials (RCTs) and systematic reviews of RCTs and cohort studies. Relevant outcomes are overall survival (OS) , morbid events, and treatment-related mortality and morbidity. Evidence from a patient-level meta-analysis of 4 RCTs comparing EVAR with open repair for elective treatment of AAAs has indicated that neither approach is clearly superior to the other. While endovascular aneurysm repair (EVAR) is associated with an early reduction in mortality, outcomes at 5 years or longer have generally shown greater reintervention rates and endovascular mortality and comparable OS rates for EVAR and open repair. Thus, the early advantage of EVAR is offset by a higher rate of late complications over the long-term. Based on these data, EVAR may be considered as an alternative to open surgery in patients who are candidates for both procedures. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have ruptured AAAs who receive endovascular stent grafts, the evidence includes RCTs, systematic reviews of RCTs, and nonrandomized comparative studies. Relevant outcomes are OS, morbid events, and treatment-related mortality and morbidity. For patients with ruptured AAAs, evidence from 3 major RCTs and 2 meta-analyses has indicated that short- and intermediate-term survival (up to 1 year) following EVAR is comparable with open repair, while perioperative complications are reduced with EVAR. Evidence from a large nonrandomized matched comparison demonstrated that EVAR is associated with a perioperative mortality benefit up to 4 years post-surgery, at the cost of the increased likelihood of the need for reintervention. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have AAAs ineligible for open repair who receive endovascular stent grafts, the evidence includes RCTs and retrospective analyses. Relevant outcomes are OS, morbid events, and treatment-related mortality and morbidity. At least 2 RCTs have compared EVAR with no surgical intervention for patients ineligible for open repair, either because of aneurysm size or prohibitive surgical risk. These trials did not report superior outcomes with EVAR and thus do not support the use of EVAR in this population. One retrospective database analysis suggests a likely benefit to EVAR in patients deemed unfit for open AAA repair, which may be reserved for those with lower Gagne Indices, larger AAA diameters, and lack of frailty, while a propensity score-matched analysis indicates a long-term survival benefit with EVAR relative to conservative management in patients with AAA deemed unfit for open repair

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based on cardiopulmonary exercise testing. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 5/2026 Policy updated with literature review through March 18, 2026; references added. Policy statements unchanged. 7/2025 Annual policy review. Policy updated with literature review through March 17, 2025; references added. Policy statements unchanged. 7/2024 Annual policy review. References updated. Policy statements unchanged. 7/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 7/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 9/2019 Outpatient prior authorization information clarified to N/A. This service is primarily performed in an inpatient setting. 6/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2018 Clarified coding information. 6/2017 Annual policy review. New references added 7/2016 Annual policy review. Policy title changed to “Endovascular Stent Grafts for Abdominal Aortic Aneurysms.” Policy statements unchanged. 7/1/2016 9/2015 Added coding language. 9/2014 Coding information clarified. 6/2014 The 2nd policy statement was editorially revised to clarify that situations that do not meet the criteria in the 1st policy statement would be considered investigational. 5/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 1/2014 Updated to add new CPT codes 34841-34848. 11/2013 Removed CPT codes 34812, 34825 & 34826 and ICD-9 diagnosis codes 441.02 & 447.72 as they do not meet the intent of the policy. 6/2013 Annual policy review. New references added 4/2013 Annual policy review. New references added 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
4/2011 Reviewed Medical Policy Group – Cardiology and Pulmonology. No changes to policy statements.
11/1/2010 BCBS Association National Policy Review. Revisions to coverage statement made, effective 11/1/2010. 4/2010 Reviewed Medical Policy Group – Cardiology. No changes to policy statements. 5/1/2009 Medical Policy 098 effective 5/1/2009.
4/2009 Reviewed - Medical Policy Group – Cardiology. No changes to policy statements. 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

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Medical Technology Assessment Guidelines

References

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19. Bulder RMA, Bastiaannet E, Hamming JF, et al. Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm. Br J Surg. Apr 2019; 106(5): 523-533. PMID 30883709
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24. Ulug P, Sweeting MJ, von Allmen RS, et al. Morphological suitability for endovascular repair, non- intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis. Lancet. Jun 24 2017; 389(10088): 2482-
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33. Becquemin JP, Pillet JC, Lescalie F, et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg. May 2011; 53(5): 1167-1173.e1. PMID 21276681
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39. Braithwaite B, Cheshire NJ, Greenhalgh RM, et al. Endovascular strategy or open repair for ruptured abdominal aortic aneurysm: one-year outcomes from the IMPROVE randomized trial. Eur Heart J. Aug 14 2015; 36(31): 2061-2069. PMID 25855369
40. Reimerink JJ, Hoornweg LL, Vahl AC, et al. Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial. Ann Surg. Aug 2013; 258(2): 248-56. PMID 23549424
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47. De Rango P, Verzini F, Parlani G, et al. Quality of life in patients with small abdominal aortic aneurysm: the effect of early endovascular repair versus surveillance in the CAESAR trial. Eur J Vasc Endovasc Surg. Mar 2011; 41(3): 324-31. PMID 21145269
48. Greenhalgh RM, Brown LC, Powell JT, et al. Endovascular repair of aortic aneurysm in patients physically ineligible for open repair. N Engl J Med. May 20 2010; 362(20): 1872-80. PMID 20382982
49. Sweeting MJ, Patel R, Powell JT, et al. Endovascular Repair of Abdominal Aortic Aneurysm in Patients Physically Ineligible for Open Repair: Very Long-term Follow-up in the EVAR-2 Randomized Controlled Trial. Ann Surg. Nov 2017; 266(5): 713-719. PMID 28742684
50. Khoury MK, Heid CA, Rectenwald JE, et al. Understanding who benefits from endovascular aortic repair in those deemed unfit for open repair. J Vasc Surg. Aug 2022; 76(2): 419-427.e3. PMID 35227800
51. Shahin Y, Dixon S, Kerr K, et al. Endovascular aneurysm repair offers a survival advantage and is cost-effective compared with conservative management in patients physiologically unfit for open repair. J Vasc Surg. Feb 2023; 77(2): 386-395.e3. PMID 36152982
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