Humana Commercial Clinical Policy

Humana Transcatheter Intravascular Stents Form

Effective Date

03/23/2023

Last Reviewed

NA

Original Document

  Reference



Description

Transcatheter intravascular stent placement is a minimally invasive procedure used to improve blood flow in obstructed (blocked) or stenosed (narrowed) arteries and veins in the abdomen, extremities or organs as an alternative to open vascular surgery. A stent (small wire mesh tube) is used in cases where percutaneous transluminal angioplasty (PTA) alone is not expected to provide a durable result or as an adjunct to suboptimal PTA. To place the stent with PTA, a catheter (thin, hollow tube) with a balloon at the tip is inserted through a vessel in the arm, groin or neck and guided to the location of the obstruction or stenosis. The balloon is inflated to expand the artery or vein and improve blood flow. Guided to the affected area, a delivery catheter places the stent to keep the vessel open.

Angiography or intravascular ultrasound (IVUS) is used during the PTA to produce images of the vascular lumen (interior of the vessel) and guide the stent placement procedure. Angiography uses an injection of radiopaque contrast dye to obtain x-ray images of the blood vessels to detect abnormalities. IVUS uses high-frequency sound waves to provide images of the blood vessel lumen to delineate plaque and lesion characteristics and distribution. Both techniques are used to evaluate blood vessel characteristics to guide treatment decisions including stent size and positioning.

A variety of conditions may be treated with transcatheter intravascular stent placement, including but not limited to:

  • Brachiocephalic or subclavian artery stenosis – Reduced blood flow through the brachiocephalic or subclavian arteries may occur with a number of conditions including, but not limited to, atherosclerosis (plaque buildup), external compression, radiation-induced arteriopathy, subclavian steal syndrome (SSS), Takayasu arteritis or thromboembolism. Exercise-induced arm pain, fatigue, numbness or upper extremity pain at rest may occur with subclavian steal syndrome when a subclavian artery occlusion or stenosis creates a flow reversal away from the arm on the same side of the body. Other symptoms include, but may not be limited to, dizziness, syncope or vertigo with upper-extremity exertion.
  • Celiac artery compression (e.g., Dunbar syndrome, median arcuate ligament syndrome [MALS]) – Chronic recurrent abdominal pain is related to compression of the celiac artery by the median arcuate ligament. Symptoms including, but not limited to, abdominal bruit, postprandial (after a meal) pain and unintentional weight loss may occur with reduced blood flow in the celiac artery. Treatment of symptomatic celiac artery compression aims to restore celiac blood flow by laparoscopic decompression of the celiac artery. For persistent or recurring symptoms, angioplasty and stent placement may be performed. (Refer to Coverage Limitations section)
  • Chronic mesenteric ischemia – Occlusions of the celiac, superior mesenteric or inferior mesenteric arteries can lead to mesenteric ischemia due to inadequate blood flow to the intestines. Mesenteric artery stenosis is most often caused by atherosclerosis and can cause chronic symptoms of diarrhea, food fear, postprandial pain and weight loss.

Transcatheter Intravascular Stents Effective Date: 03/23/2023
Revision Date: N/A
Review Date: 03/23/2023
Policy Number: HUM-0619-000

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Transcatheter Intravascular Stents

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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Hemodialysis (HD) arteriovenous (AV) fistula or graft stenosis or thrombosis – A stenotic lesion can develop and cause narrowing at any point in the HD access circuit where there is turbulent blood flow. As the lesion progresses, it decreases blood flow and can lead to failure of the AV fistula or graft and inability to successfully manage hemodialysis.
  • Hepatic venous outflow tract obstruction (eg, Budd-Chiari syndrome) – Primary Budd-Chiari syndrome is caused by obstruction due to a predominantly venous process (eg, phlebitis, thrombosis), whereas secondary Budd-Chiari syndrome occurs with compression of the hepatic veins and/or the inferior vena cava by a lesion outside the vein (eg, malignancy, tumor). Left untreated, Budd-Chiari syndrome can cause ascites, hepatic necrosis and liver failure.

Systemic veins of the abdomen and pelvis can be due to one of several etiologies including, but not limited to, an endoluminal obstruction related to an endoluminal device, thrombosis or vein wall injury. Most etiologies are predominantly thrombotic or nonthrombotic but may lead to thrombosis depending on the severity of the obstruction. Obstruction of the iliac veins and/or vena cava may result in severe lower extremity symptoms including, but not limited to, chronic pain, edema and nonhealing ulcerations.

  • Iliocaval venous outflow tract obstruction (eg, May-Thurner syndrome, also known as iliac vein compression syndrome or Cockett’s syndrome) – Extrinsic compression of the left iliac vein by the arterial system against bony structures in the iliocaval territory results in interrupted blood flow through the legs back to the heart. This may cause pooling of blood in the legs and lead to deep vein thrombosis (DVT) with associated pain, swelling and/or ulcers (open sores).
  • Peripheral vascular disease – Stenosis or obstruction occurs when blood flow is restricted in vessels that lead to the upper extremities and internal organs (eg, kidneys, stomach). Venous stenosis most commonly affects the axillary, brachial, cephalic or brachiocephalic veins of the upper extremities, or the superior vena cava, but can also affect the central veins in the abdomen. Common causes include, but may not be limited to, embolism, extrinsic compression, thrombosis or stenosis from placement of central venous catheters, hemodialysis catheters and pacemaker leads.

Transcatheter Intravascular Stents Effective Date: 03/23/2023
Revision Date: N/A
Review Date: 03/23/2023
Policy Number: HUM-0619-000
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This may be due to the presence of unfavorable lesion morphology (structure) including, but not limited to, residual stenosis of more than 30% for a vein measured at the narrowest point of the vascular lumen at the site of the angioplasty or more than 50% reduction of lumen diameter; a tear in the intima (inner lining) or vascular lumen; or persistent occlusion or dissection at the angioplasty site, elastic recoil occlusion or refractory spasm.

  • Superior vena cava syndrome Blood flow is reduced or blocked by either the direct invasion or external compression of the vessel by a benign or malignant tumor, stenosis caused by post-radiation vasculopathy (radiation-induced vascular stenosis) or thrombosis.

Transcatheter intravascular stent placement for intracranial arteries and venous femoral-popliteal or tibial-peroneal segments are not addressed in this medical coverage policy.

For information regarding other transcatheter intravascular stent placements not addressed in this policy, please see the following Medical Coverage Policies:

Stent Placement:
Carotid artery - Carotid Revascularization
Coronary artery - Coronary Stents and Angioplasty
Lower extremity - Peripheral Artery Revascularization of the Lower Extremities
artery occlusive disease

Transcatheter Intravascular Stents Effective Date: 03/23/2023
Revision Date: N/A
Review Date: 03/23/2023
Policy Number: HUM-0619-000
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Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination

Transcatheter intravascular stent procedures deemed urgent/emergent (e.g., acute ischemia, spontaneous artery dissection) are not subject to the criteria within this medical coverage policy.

Humana members may be eligible under the Plan for transcatheter intravascular stent placement using a US Food & Drug Administration (FDA)-approved stent for the following indications:

  • Brachiocephalic or subclavian artery stenosis (e.g., atherosclerosis, external compression, radiation-induced arteriopathy, subclavian steal syndrome, Takayasu arteritis, thrombo-embolism); AND
    • Diagnosis confirmed by computed tomography angiography (CTA);AND EITHER of the following:
      • Symptoms with upper-extremity exertion such as dizziness, and/or lightheadedness, and/or syncope and/or vertigo;
      • Upper extremity ischemia (e.g., arm and/or hand claudication, and/or paresthesia and/or rest pain);
  • Chronic mesenteric ischemia with stenosis greater than 70% within the celiac axis and/or superior mesenteric artery (SMA) and BOTH of the following:
    • Diagnosis confirmed by CTA, duplex Doppler ultrasound or MRA; AND
    • Symptoms such as diarrhea, and/or food fear, and/or postprandial pain and/or weight loss;
  • Hepatic venous outflow obstruction (e.g., Budd-Chiari syndrome) and BOTH of the following:
    • Diagnosis confirmed by computed tomography (CT), Doppler ultrasound or magnetic resonance imaging (MRI); AND

Transcatheter Intravascular Stents Effective Date: 03/23/2023
Revision Date: N/A
Review Date: 03/23/2023
Policy Number: HUM-0619-000
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  • Symptoms such as abdominal pain, and/or distension and/or hepatomegaly; OR
  • Iliac vein compression syndrome (eg, iliocaval venous outflow tract obstruction, May-Thurner or Cockett syndrome) and BOTH of the following:
    • Diagnosis confirmed by CTA or MRA; AND
    • Moderate to severe symptoms (limb swelling, and/or pain and/or Clinical, Etiologic, Anatomic, Pathophysiologic [CEAP] clinical classes 4 to 6 hyperpigmentation and/or ulceration); OR
  • Iliocaval venous occlusion with BOTH of the following:
    • Diagnosis confirmed by venous duplex ultrasound; AND
    • Moderate to severe symptoms (pain, and/or swelling and/or CEAP clinical classes 3 to 6 hyperpigmentation and/or ulceration); OR
  • Iliofemoral venous obstruction confirmed by Doppler ultrasound, CT or magnetic resonance venography (MRV); AND
    • 1 or more of the following:
      • Symptoms (eg, edema and/or pain that limits daily functioning) not relieved by conservative therapies (eg, compression and/or medication); OR
      • Venous lower extremity ulceration; OR
  • Pulmonary vein stenosis greater than or equal to 60% stenosis and BOTH of the following:
    • Diagnosis confirmed by echocardiography and/or CTA; AND
    • Stenosis resulting from congenital malformation, extrinsic compression, sequelae of radiofrequency ablation (RFA), lung transplantation or post repair of total anomalous pulmonary vein return (TAPVR); OR
  • Renal artery stenosis (RAS) with atherosclerotic diagnosis confirmed by CTA, duplex Doppler ultrasound or magnetic resonance imaging (MRI); AND
    • any of the following:
      • Bilateral RAS with greater than 70% stenosis of both arteries with intolerance (eg, deterioration of renal function during antihypertensive medication therapy) or failure to control blood pressure with optimal guideline medical therapy (GDMT)*; OR
      • Hemodynamically significant (eg, presence of end-organ dysfunction) bilateral or solitary kidney RAS and EITHER of the following:
        • Diameter stenosis of 50 – 70 % confirmed by CTA with a peak translesional gradient of greater than or equal to 20 mm Hg or a mean gradient greater than or equal to 10 mm Hg; OR
        • Greater than or equal to 70% diameter stenosis confirmed by CTA;
        AND
        • 1 or more of the following:
          • Recurrent, refractory or sudden unexplained (flash) pulmonary edema; OR
          • Stroke; OR
          • Uncontrolled blood pressure despite optimal GDMT*;
          • Unstable angina; OR
          • Vision loss; OR
          • Individual with chronic end-stage renal disease (ESRD) on hemodialysis for less than or equal to 3 months; OR

    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000
    Page: 7 of 19

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000
    Page: 8 of 19

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

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    • Unilateral or solitary kidney RAS with intolerance (eg, deterioration of renal function during antihypertensive medication therapy) or failure to control blood pressure with optimal GDMT*; AND 1 or more of the following:
      • Chronic kidney disease (CKD) with estimated glomerular filtration rate (eGFR) less than 45 ml/min; OR
      • Kidney size greater than or equal to 7 cm pole-to-pole length; OR
      • Prior episode of heart failure (HF) Stage C;
    • Salvage of thrombosed or stenotic arteriovenous dialysis access fistula or graft with compromised venous outflow (narrowing of the vascular lumen greater than or equal to 50%) confirmed by Doppler ultrasound or fistulography; OR
    • Suboptimal or failed percutaneous transluminal angioplasty (PTA) due to the presence at the angioplasty site of ANY of the following:
      • Acute vessel occlusion immediately post-PTA; OR
      • Flow-limiting dissection; OR
      • Occlusion elastic recoil or refractory spasm; OR
      • Recurrence of lesion with a greater than or equal to 50% reduction of lumen diameter within 12 months post-PTA; OR
      • Residual stenosis greater than or equal to 30% at the narrowest point of the vascular lumen or resulting in greater than or equal to 50% reduction in vessel diameter; OR
      • Trans-stenotic pressure gradient greater than or equal to 5 mmHg;
    • Superior vena cava syndrome and BOTH of the following:
      • Diagnosis confirmed by CT, duplex Doppler ultrasound or MRI; AND
      • Source of obstruction is malignant compression, and/or post radiation stenosis and/or thrombosis);
    • Venous stenosis greater than 50% of the diameter of the affected vein or residual stenosis of greater than or equal to 30% measured after angioplasty

    *GDMT for renal artery stenosis includes angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), calcium channel blockers and diuretics.

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    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Coverage Limitations

    Humana members may NOT be eligible under the Plan for transcatheter intravascular stents for any indications other than those listed above including, but may not be limited to:

    • Prevention of stenosis (eg, asymptomatic with no functional limitation)
      This is considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.
    • Celiac artery compression syndrome (eg, Dunbar syndrome, median arcuate ligament syndrome [MALS])
      This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

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    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

    Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Additional information about atherosclerosis may be found from the following websites:

    • American Heart Association
    • National Library of Medicine

    Medical Alternatives

    Alternatives to transcatheter intravascular stent placement include, but may not be limited to, the following:

    • Prescription drug therapy
    • Surgical revascularization

    Physician consultation is advised to make an informed decision based on an individual’s health needs.

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    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

    CPT® Code(s)

    Description Comments

    • 37236 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery
    • 37237 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)
    • 37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein
    • 37239 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure)
    • 37253 Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)
    • CPT® Category Ill Code(s) No code(s) identified

    HCPCS Code(s)

    Description Comments

    • No code(s) identified

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    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

    References

    • Agency for Healthcare Research and Quality (AHRQ). Comparative Effectiveness Review (ARCHIVED). Renal artery stenosis management strategies.

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    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Page: 14 of 19

    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

    When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    1. ClinicalKey. Clinical Overview. Renal artery stenosis. https://www.clinicalkey.com. Updated January 1, 2023. Accessed March 9, 2023.
    2. ClinicalKey. Kinlay S, Bhatt DK. Treatment of noncoronary obstructive vascular disease. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022:1145-1162.e7. https://www.clinicalkey.com. Accessed March 5, 2023.
    3. ClinicalKey. Salahuddin T, Armstrong EJ. Intervention for iliofemoral deep vein thrombosis and May-Thurner syndrome. Interv Cardiol Clin. 2020;9(2):243-254. https://www.clinicalkey.com. Accessed May 9, 2023.
    4. Hayes, Inc. Medical Technology Directory (ARCHIVED). Endovascular stents for the treatment of atherosclerotic renal artery stenosis. https://evidence.hayesinc.com. Published September 18, 2009. Updated September 9, 2013. Accessed March 5, 2023.
    5. MCG Health. Angioplasty, renal. 26th edition. https://www.mcg.com. Accessed February 10, 2023.
    6. Merck Manual: Professional Version. Budd-Chiari syndrome. https://www.merckmanuals.com. Updated September 2022. Accessed March 10, 2023.
    7. Merck Manual: Professional Version. Renal artery stenosis and occlusion. https://www.merckmanuals.com. Updated September 2022. Accessed March 10, 2023.
    8. Pazos-Lopez P, Garcia-Rodriquez C, Guitian-Gonzalez A, et al. Pulmonary vein stenosis: etiology, diagnosis and management. World J Cardiol. 2016;8(1):81-88.
    9. Society for Cardiovascular Angiography & Interventions (SCAI). SCAI appropriate use criteria for peripheral arterial intervention: an update. https://www.scai.org. Published May 5, 2017. Accessed March 7, 2023.
    10. Society for Cardiovascular Angiography & Interventions (SCAI). SCAI expert consensus statement for renal artery stenting appropriate use. https://www.scai.org. Published August 19, 2014. Accessed March 7, 2023.
    11. Society for Vascular Surgery (SVS). Chronic mesenteric ischemia: clinical practice guidelines from the Society for Vascular Surgery. https://www.vascular.org. Published November 7, 2020. Accessed March 8, 2023.
    12. Society of Interventional Radiology (SIR). ACR-SIR practice parameter for endovascular management of the thrombosed or dysfunctional dialysis access. https://www.sirweb.org. Published 2004. Updated 2021. Accessed March 9, 2023.
    13. Society of Interventional Radiology (SIR). ACR-SIR practice parameter for the performance of angiography, angioplasty and stenting for the diagnosis and treatment of renal artery stenosis in adults. https://www.sirweb.org. Published 2004. Updated 2021. Accessed March 9, 2023.
    14. Society of Interventional Radiology (SIR). Standards of Practice. Quality improvement guidelines for percutaneous image-guided management of the thrombosed or dysfunctional dialysis circuit. https://www.sirweb.org. Published July 14, 2016. Accessed March 10, 2023.
    15. UpToDate, Inc. Basic principles of vascular stents used in hemodialysis arteriovenous access intervention. https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.

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    Transcatheter Intravascular Stents Effective Date: 03/23/2023
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    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

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    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    1. UpToDate, Inc. Budd-Chiari syndrome: epidemiology, clinical manifestations and diagnosis. https://www.uptodate.com. Updated February 2023. Accessed March 8, 2023.
    2. UpToDate, Inc. Budd-Chiari syndrome: management.https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.

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    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

    1. UpToDate, Inc. Celiac artery compression syndrome. https://www.uptodate.com. Updated February 22, 2023. Accessed March 15, 2023.
    2. UpToDate, Inc. Central venous obstruction associated with upper extremity hemodialysis access. https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.
    3. UpToDate, Inc. Determining the etiology and severity of heart failure or cardiomyopathy. https://www.uptodate.com. Updated February 2023. Accessed March 9, 2023.
    4. UpToDate, Inc. Embolism to the upper extremities.https://www.uptodate.com. Updated February 2023. Accessed March 3, 2023.
    5. UpToDate, Inc. Endovascular intervention for the treatment of stenosis in the arteriovenous access. https://www.uptodate.com. Updated February 2023. Accessed March 7, 2023.
    6. UpToDate, Inc. Endovenous interventions for iliocaval venous obstruction. https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.
    7. UpToDate, Inc. Malignancy-related superior vena cava. https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.
    8. UpToDate, Inc. May-Thurner syndrome. https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.
    9. UpToDate, Inc. Mediastinal granuloma and fibrosing mediastinitis. https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.
    10. UpToDate, Inc. Overview of iliocaval venous obstruction. https://www.uptodate.com. Updated February 2023. Accessed March 5, 2023.
    11. UpToDate, Inc. Overview of thoracic outlet syndromes. https://www.uptodate.com. Updated February 2023. Accessed March 10, 2023.

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    Transcatheter Intravascular Stents Effective Date: 03/23/2023
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    Review Date: 03/23/2023
    Policy Number: HUM-0619-000

    1. UpToDate, Inc. Subclavian steal syndrome. https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.
    2. UpToDate, Inc. Surgical and endovascular techniques for mesenteric revascularization. https://www.uptodate.com. Updated February 2023. Accessed March 3, 2023.
    3. UpToDate, Inc. Treatment of bilateral atherosclerotic renal artery stenosis or stenosis to a solitary functioning kidney. https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.
    4. UpToDate, Inc. Treatment of fibromuscular dysplasia of the renal arteries. https://www.uptodate.com. Updated February 2023. Accessed March 9, 2023.
    5. UpToDate, Inc. Treatment of unilateral atherosclerotic renal artery stenosis. https://www.uptodate.com. Updated February 2023. Accessed March 4, 2023.

    Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Appendix A

    CEAP Classification for Chronic Venous Disorders

    C0: No visible or palpable signs of venous disease
    C1: Telangiectasias, reticular veins
    C2: Varicose veins
    C2r: Recurrent varicose veins
    C3: Edema
    C4: Changes in skin and subcutaneous tissue secondary to chronic venous disease
    C4a: Pigmentation or eczema
    C4b: Lipodermatosclerosis or atrophie blanche
    C4c: Corona phlebectatica
    C5: Healed venous ulcer
    C6: Active venous ulcer

    Appendix B

    Stages in the Development of Heart Failure (HF)

    Stage A: At high risk for HF but without structural heart disease or symptoms of HF.
    Stage B: Structural heart disease but without signs or symptoms of HF. This stage includes the individual in New York Heart Association (NYHA) functional class I with no prior or current symptoms or signs of HF.
    Stage C: Structural heart disease with prior or current symptoms of HF. This stage includes the individual with any NYHA functional class (including class I with prior symptoms).
    Stage D: Refractory HF requiring specialized interventions. This stage includes the individual in NYHA functional class IV with refractory HF.

    Transcatheter Intravascular Stents Effective Date: 03/23/2023
    Revision Date: N/A
    Review Date: 03/23/2023
    Policy Number: HUM-0619-000
    Page: 19 of 19

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    Appendix C

    Classification of Hemodialysis Access Site Hematoma

    Grade 1: Self-limited, stable hematoma
    No alteration in blood flow through vascular access
    Nominal therapy required (such as warm compresses or similar for symptom management)
    Grade 2: Hematoma
    Reduction in blood flow through vascular access
    Minor therapy required (such as stent or stent graft placement)
    Grade 3: Unstable (expanding) hematoma
    Reduction in blood flow through vascular access
    Major therapy required (such as surgical repair or drainage and/or transfusion for blood loss)
    Grade 4: Compressive hematoma
    Permanent loss of vascular access
    Permanent impairment requiring alternative access (existing access unable to be salvaged)