Humana Elective Aorta and Iliac Artery Aneurysm Repair Form

Description

An arterial aneurysm is defined as a permanent localized dilatation (weakening or ballooning) in the wall of an artery that is 150% of the diameter of the normal adjacent artery. 23 The aorta is the largest artery in the body, which carries blood from the heart through the chest and abdomen. Although an aneurysm can develop in any part of the aorta, abdominal aortic aneurysms (AAAs) are the most common. Thoracic aortic aneurysms (TAAs) can develop in the thoracic aorta, which is a continuation of the aortic arch located in the thorax (between the neck and the abdomen). Iliac artery aneurysms (IAAs) are another type of aneurysm that can develop in the iliac arteries supplying blood to the pelvis and legs on the right and left sides of the body. Enlargement of an aneurysm increases the risk of death from dissection (tear in the inner layer of the aorta) or rupture.

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 2 of 29

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.

Aortic aneurysms are generally asymptomatic and are frequently found incidentally during a physical examination or as part of an evaluation for another medical problem. Risk factors for aneurysmal disease include age, atherosclerotic disease, comorbidities (eg, cardiac, pulmonary, renal disease), gender, genetic mutations, hypertension and peripheral arterial disease. Aortic aneurysms are also associated with peripheral aneurysms (eg, femoral, iliac or popliteal). Aneurysmal degeneration of the iliac arteries can occur in isolation or in association with other large vessel aneurysms (eg, abdominal aorta).

Like AAAs, iliac artery aneurysms (IAAs) have a propensity for life threatening rupture as diameter increases.32

For information regarding genetic mutations often associated with aneurysms, please refer to Genetic Testing for Ehlers-Danlos Syndrome and Genetic Testing for Marfan Syndrome and Related Conditions Coverage Policies.

Contingent on the etiology, size or type (eg, fusiform, saccular) of the aneurysm and the rate of growth, treatment varies from active monitoring and surveillance to elective or emergent surgery. As with other elective surgeries, consideration of standard operative risks often determines the timing or type of treatment.

Aneurysm repair is performed with open surgery (open aneurysm repair [OAR]) or an endovascular approach (endovascular aneurysm repair [EVAR], fenestrated endovascular aneurysm repair [FEVAR] or thoracic endovascular aneurysm repair [TEVAR]).

OAR is performed using a transabdominal or retroperitoneal incision and cross clamping of the aorta. The synthetic graft replaces the diseased segment of the aorta to support blood flow through the artery.

EVAR, FEVAR and TEVAR are minimally invasive approaches performed by inserting an endograft (a fabric-covered wire frame) through the femoral arteries (in the groin) into the aorta. The endograft is deployed and secured in place to reinforce the weakened artery wall and reduce the risk of aneurysm leak and/or rupture.

US Food & Drug Administration (FDA)-approved endografts are fenestrated (branched to protect blood flow to other blood vessels) or nonfenestrated. For IAAs that are associated with AAAs, a bifurcated (branched) graft may be necessary. The type and size of endograft used are generally dictated by the arterial anatomy, aneurysm location or size and surgeon preference.

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 3 of 29

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

Aorta and iliac artery aneurysm repairs deemed urgent/emergent are not subject to the criteria within this medical coverage policy.

ABDOMINAL AORTIC ANEURYSM (AAA) REPAIR

Open (Surgical) AAA Repair

Humana members may be eligible under the Plan for open (surgical) aneurysm repair (OAR) of a radiographically confirmed AAA for the following indications:

• Absence of contraindications;
• AND any of the following:
• Aneurysm diameter greater than or equal to 5 cm in a female; OR
• Aneurysm diameter greater than or equal to 5.5 cm in a male; OR
• Aneurysm diameter growth rate confirmed by imaging (eg, computed tomography [CT], magnetic resonance imaging [MRI], transthoracic echocardiogram [TTE]) is greater than or equal to 1 cm within 1 year or at least 0.5 cm within 6 months; OR
• Complications (eg, endoleak) from a previously placed endograft; OR
• Individual requires chemotherapy, radiation therapy or solid organ transplant with aneurysm diameter 4 – 5.4 cm; OR
• Infectious aortitis with aneurysm; OR
• Marfan syndrome and a nondissected aneurysm diameter greater than or equal to 5 cm; OR
• Saccular aneurysm

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 4 of 29

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.

Endovascular Aneurysm Repair of AAA

Humana members may be eligible under the Plan for endovascular aneurysm repair (EVAR) of radiographically confirmed AAA for the following indications:

• Absence of contraindications;
• AND any of the following:
• Aneurysm diameter greater than or equal to 5 cm in a female; OR
• Aneurysm diameter greater than or equal to 5.5 cm in a male; OR
• Aneurysm diameter growth rate confirmed by imaging (eg, CT, MRI, TTE) is greater than or equal to 1 cm within 1 year or at least 0.5 cm within 6 months; OR
• Complications (eg, endoleak) from a previously placed endograft); OR
• Individual requires chemotherapy, radiation therapy or solid organ transplant with aneurysm diameter 4 – 5.4 cm; OR
• Marfan syndrome and a nondissected aneurysm diameter greater than or equal to 5 cm; OR
• Saccular aneurysm

Fenestrated Endovascular Aneurysm Repair of AAA

Humana members may be eligible under the Plan for fenestrated endovascular aneurysm repair (FEVAR) of radiographically confirmed AAA for the following indications:

• Absence of contraindications; AND
• Non-aneurysmal infrarenal aortic segment (neck) proximal to the aneurysm; AND

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 5 of 29

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.

• Aortic neck length that is greater than or equal to 4 mm and not suitable for a non-fenestrated graft; AND
• Aortic diameter of 19 – 31 mm measured outer wall to outer wall; AND
• Aortic neck angle less than 45 degrees relative to the long axis of the aneurysm; AND
• Aortic neck angle less than 45 degrees relative to the axis of the suprarenal aorta; AND

• Ipsilateral iliac artery fixation site greater than 30 mm in length and 9 – 21 mm in diameter; AND
• Contralateral iliac artery distal fixation site greater than 30 mm in length and 7 – 21 mm in diameter;

AND any of the following:

• Aneurysm diameter greater than or equal to 5 cm in a female; OR
• Aneurysm diameter greater than or equal to 5.5 cm in a male; OR
• Aneurysm diameter growth rate confirmed by imaging (eg, CT, MRI, TTE) is greater than or equal to 1 cm within 1 year or at least 0.5 cm within 6 months; OR
• Complications (eg, endoleak) from a previously placed endograft; OR
• Individual requires chemotherapy, radiation therapy or solid organ transplant with aneurysm diameter 4 – 5.4 cm; OR
• Marfan syndrome and a nondissected aneurysm diameter greater than or equal to 5 cm; OR
• Saccular aneurysm

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 6 of 29

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

Abdominal Aortic Aneurysm (AAA) Repair

Humana members may NOT be eligible under the Plan for open (surgical) aneurysm repair (OAR) of a radiographically confirmed AAA for any indications other than those listed above, including for individuals in whom the procedure is contraindicated due to prohibitive perioperative mortality risk. 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.

Humana members may NOT be eligible under the Plan for endovascular aneurysm repair (EVAR) or fenestrated endovascular aneurysm repair (FEVAR) of radiographically confirmed AAA for any indications other than those listed above or for the following contraindications:

• Anatomy prohibits placement of an endograft; OR
• Circumferential aortic calcification; OR
• Inability to comply with long term postoperative surveillance; OR
• Insufficient vascular access; OR
• Prohibitive perioperative mortality risk

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Coverage Determination

Aorta and iliac artery aneurysm repairs deemed urgent/emergent are not subject to the criteria within this medical coverage policy.

THORACIC AORTIC ANEURYSM (TAA) REPAIR

Open (Surgical) TAA Repair

Humana members may be eligible under the Plan for open (surgical) thoracic aneurysm repair (OTAR) of a radiographically confirmed TAA for the following indications:

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 7 of 29

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.

• Absence of contraindications; AND any of the following:
• Asymptomatic aortic arch aneurysm at low perioperative mortality risk per an evidence-based decision tool (eg, ASC NSQIP Surgical Risk Calculator) and arch diameter greater than or equal to 5.5 cm; OR
• Asymptomatic aortic root or ascending aortic aneurysm and ANY of the following:
  • Aneurysm aortic size index (ASI)* greater than or equal to 3.08 cm/m2 or aortic height index (AHI)** greater than or equal to 3.21 cm/m; OR
  • Aneurysm diameter greater than or equal to 5 cm; OR
  • Aneurysm diameter less than 5 cm and EITHER:
    • Aneurysm growth rate confirmed by imaging (eg, CT, MRI, TTE) is greater than or equal to 0.3 cm within a year for 2 consecutive years or greater than or equal to 0.5 cm within 1 year; OR
    • High risk for aortic rupture; OR
• Asymptomatic descending aortic aneurysm and EITHER of the following:
  • Aneurysm diameter greater than or equal to 5.5 cm; OR
  • Aneurysm diameter less than 5.5 cm and EITHER:
    • Aneurysm growth rate confirmed by imaging (eg, CT, MRI, TTE) greater than or equal to 0.5 cm within 1 year; OR
    • High risk for aortic rupture; OR
• Aneurysm diameter greater than or equal to 4.5 cm and undergoing aortic valve repair or replacement; OR
• Aneurysm diameter greater than or equal to 5 cm and undergoing open cardiac surgery other than aortic valve repair or replacement; OR
• Bicuspid aortic valve present with aortic root and/or ascending aortic aneurysm diameter greater than or equal to 5 cm; OR
• Complications (eg, endoleak) from a previously placed endograft; OR
• Individual with ANY of the following high risk factors for aortic rupture:
  • Infectious aortitis with aneurysm; OR
  • Saccular aneurysm; OR
• Individual with Ehlers-Danlos syndrome (EDS) or familial thoracic aortic aneurysm/dissection (TADD) syndrome and an aneurysm diameter greater than or equal to 4.5 cm; OR
• Individual with Loeys-Dietz syndrome (LDS) with aneurysm diameter greater than or equal to 4 cm AND 1 or more of the following:
  • Aneurysm diameter growth rate confirmed by imaging (eg, CT, MRI, TTE) is greater than 0.3 cm within 1 year; OR
  • First-degree relative with history of aortic dissection; OR
• Individual with Marfan syndrome with ANY of the following:
  • Aortic arch or descending thoracic aortic aneurysm diameter greater than or equal to 5 cm; OR
  • Maximal cross-sectional aortic root area (cm2) to patient height (m) ratio of greater than or equal to 10 cm2/m; OR
  • Aortic root aneurysm diameter greater than or equal to 4.5 cm AND 1 or more of the following:

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 8 of 29

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.

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

• Aortic root growth confirmed by imaging (eg, CT, MRI, TTE) is greater than or equal to 0.3 cm within 1 year; OR
• Aortic or mitral regurgitation; OR
• First-degree relative with history of Marfan syndrome with aortic dissection; OR
• Vascular fragility (eg, arterial tortuosity); OR
• Individual with Turner syndrome 15 years of age or older and aortic root or ascending aortic aneurysm with ASI* greater than or equal to 2.5 cm/m2 AND 1 or more of the following:
  • Aortic coarctation; OR
  • Bicuspid aortic valve; OR
  • Hypertension (BP greater than or equal to 130/80); OR
• Nonsyndromic heritable thoracic aortic disease (nsHTAD) with no identifiable genetic cause and ALL of the following:
  • Asymptomatic aortic root or ascending aortic aneurysm diameter greater than or equal to 5 cm; AND
  • First-degree relative with history of aortic dissection; AND
  • Absence of high risk factors for aortic rupture; OR
• Pregnancy planned and ANY of the following:
  • BAV (without Turner syndrome or heritable thoracic aortic disease [HTAD]) with aneurysm diameter greater than or equal to 5 cm; OR
  • Loeys-Dietz syndrome with aneurysm diameter greater than or equal to 4 cm; OR
  • Marfan syndrome with EITHER:

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 10 of 29

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.

• Aneurysm greater than 4.5 cm; OR
• Aneurysm 4 – 4.5 cm AND 1 or more of the following:
  • Aortic root growth confirmed by imaging (eg, CT, MRI, TTE) is greater than or equal to 0.3 cm within 1 year; OR
  • First-degree relative with history of Marfan syndrome with aortic dissection; OR
  • nsHTAD with aneurysm diameter greater than 4.5 cm; OR
  • Sporadic aortic root and/or ascending aortic aneurysm diameter greater than or equal to 5 cm; OR
  • Turner syndrome with ASI* greater than or equal to 2.5 cm/m2

*ASI is the ratio of aortic size (diameter) in centimeters divided by body surface area (BSA) in meters2. BSA is calculated using the DuBois Method. **AHI is the ratio of aortic size (diameter) in centimeters divided by height in meters.

Thoracic Endovascular Aneurysm Repair of TAA

Humana members may be eligible under the Plan for thoracic endovascular aneurysm repair (TEVAR) of a radiographically confirmed TAA for the following indications:

• Absence of contraindications; AND any of the following:
• Asymptomatic descending aortic aneurysm and EITHER of the following:
  • Aneurysm diameter greater than or equal to 5.5 cm; OR
  • Aneurysm diameter less than 5.5 cm

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 11 of 29

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.

• 5 cm and EITHER:
• Aneurysm growth rate confirmed by imaging (eg, CT, MRI, TTE) greater than or equal to 0.5 cm within 1 year; OR
• High risk for aortic rupture; OR
• Aneurysm diameter greater than or equal to 4.5 cm and undergoing aortic valve repair or replacement; OR
• Aneurysm diameter greater than or equal to 5 cm and undergoing open cardiac surgery other than aortic valve repair or replacement; OR
• Complications (eg, endoleak) from a previously placed endograft; OR
• Individual with Ehlers-Danlos syndrome (EDS) or familial thoracic aortic aneurysm/dissection (TADD) syndrome and an aneurysm diameter greater than or equal to 4.5 cm; OR
• Individual with Loeys-Dietz syndrome (LDS), aortic arch or descending aorta aneurysm diameter greater than or equal to 4 cm AND 1 or more of the following:
• Aneurysm growth rate confirmed by imaging (eg, CT, MRI, TTE) is greater than 0.3 cm within 1 year; OR
• First-degree relative with history of aortic dissection; OR
• Individual with Marfan syndrome with ANY of the following:
• Aortic arch or descending thoracic aortic aneurysm diameter greater than or equal to 5 cm; OR
• Maximal cross-sectional aortic root area (cm2) to patient height (m) ratio of greater than or equal to 10 cm2/m; OR
• Aortic root aneurysm diameter greater than or equal to 4.5 cm AND 1 or more of the following:
• Aortic root growth confirmed by imaging (eg, CT, MRI, TTE) is greater than or equal to 0.3 cm within 1 year; OR
• Aortic or mitral regurgitation; OR
• First-degree relative with history of Marfan syndrome with aortic dissection; OR
• Vascular fragility (eg, arterial tortuosity); OR

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 12 of 29

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.

• Individual with Turner syndrome 15 years of age or older and aortic root or ascending aortic aneurysm with ASI* greater than or equal to 2.5 cm/m2 AND 1 or more of the following:
• Aortic coarctation; OR
• Bicuspid aortic valve; OR
• Hypertension (BP greater than or equal to 130/80); OR
• Nonsyndromic heritable thoracic aortic disease (nsHTAD) with no identifiable genetic cause and ALL of the following:
• Asymptomatic aortic root or ascending aortic aneurysm diameter greater than or equal to 5 cm; AND
• First-degree relative with history of aortic dissection; AND
• Absence of high risk factors for aortic rupture; OR
• Saccular aneurysm; OR
• Pregnancy planned and ANY of the following:
• Marfan syndrome with either:

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 13 of 29

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.

• Aneurysm greater than 4.5 cm; OR
• Aneurysm 4 – 4.5 cm AND 1 or more of the following:
  • Aortic root growth confirmed by imaging (eg, CT, MRI, TTE) is greater than or equal to 0.3 cm within a year; OR
  • First-degree relative with history of Marfan syndrome with aortic dissection; OR
  • nsHTAD with aneurysm diameter greater than 4.5 cm

Coverage Thoracic Aortic Aneurysm (TAA) Repair

Coverage Limitations

Thoracic Aortic Aneurysm (TAA) Repair

Humana members may NOT be eligible under the Plan for open (surgical) thoracic aneurysm repair of radiographically confirmed TAA (OTAR) for any indications other than those listed above, including for individuals in whom the procedure is contraindicated due to prohibitive risk for perioperative mortality and morbidity per an evidence-based decision tool (eg, ASC NSQIP Surgical Risk Calculator).

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.

Humana members may NOT be eligible under the Plan for thoracic endovascular aneurysm repair (TEVAR) of a TAA for any indications other than those listed above or for the following contraindications:

• Anatomy prohibits placement of an endograft; OR
• Inability to comply with long term postoperative surveillance; OR
• Insufficient vascular access; OR
• Prohibitive risk for perioperative mortality and morbidity (per an evidence-based decision tool [eg, ASC NSQIP Surgical Risk Calculator])

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 14 of 29

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.

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Coverage Determination

Aorta and iliac artery aneurysm repairs deemed urgent/emergent are not subject to the criteria within this medical coverage policy.

ILIAC ARTERY ANEURYSM (IAA) REPAIR

Open (Surgical) IAA Repair

Humana members may be eligible under the Plan for open (surgical) aneurysm repair (OAR) of radiographically confirmed IAA for the following indications:

• Absence of contraindications; AND any of the following:
• Aneurysm greater than or equal to 3.0 cm in diameter; OR
• Aneurysm diameter growth rate confirmed by imaging (eg, CT, MRI, TTE) is greater than or equal to 1 cm within 1 year or at least 0.5 cm within 6 months; OR
• Asymptomatic aneurysm greater than or equal to 3.5 cm associated with concomitant AAA that meets criteria for AAA repair; OR
• Complications (eg, endoleak) from a previously placed endograft

Endovascular Aneurysm Repair of IAA

Humana members may be eligible under the Plan for endovascular aneurysm repair (EVAR) of radiographically confirmed IAA for the following indications:

• Absence of contraindications;

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 15 of 29

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.

• AND any of the following:
• Aneurysm greater than or equal to 3.0 cm in diameter; OR
• Aneurysm diameter growth rate confirmed by imaging (eg, CT, MRI, TTE) is greater than or equal to 1 cm within 1 year or at least 0.5 cm within 6 months; OR
• Asymptomatic aneurysm greater than or equal to 3.5 cm associated with concomitant AAA that meets criteria for AAA repair; OR
• Complications (eg, endoleak) from a previously placed endograft

Coverage Iliac Artery Aneurysm (IAA) Repair

Coverage Limitations

Iliac Artery Aneurysm (IAA) Repair Humana members may NOT be eligible under the Plan for open (surgical) aneurysm repair (OAR) of an IAA for any indications other than those listed above, including for individuals in whom the procedure is contraindicated due to prohibitive risk for perioperative mortality and morbidity per an evidence-based decision tool (eg, ASC NSQIP Surgical Risk Calculator). 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.

Humana members may NOT be eligible under the Plan for endovascular aneurysm repair (EVAR) of an IAA for any indications other than those listed above or for the following contraindications:

• Anatomy prohibits placement of an endograft; OR
• Inability to comply with long term postoperative surveillance; OR
• Insufficient vascular access; OR
• Prohibitive risk for perioperative mortality and morbidity (per an evidence-based decision tool [eg, ASC NSQIP Surgical Risk Calculator])

Elective Aorta and Iliac Artery Aneurysm Repair

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0589-004 Page: 16 of 29

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.

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about abdominal aortic, iliac artery or thoracic aortic aneurysms may be found from the following websites:

• BackgroundAmerican Heart Association
• National Heart, Lung and Blood Institute
• National Library of Medicine
• Society for Vascular Surgery

Medical Alternatives

Alternatives to elective aorta or iliac artery aneurysm repair include, but may not be limited to, the following:

• Active monitoring and surveillance

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

Humana may offer a disease management program for this condition. The member may call the number on his/her identification card to ask about our programs to help manage his/her care.