Humana Elective Aorta and Iliac Artery Aneurysm Repair - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals.

There are no NCDs and/or LCDs for elective aorta and iliac artery aneurysm repair.

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. 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.

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.

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.

Coverage Determination

Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria:

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Elective Aorta and Iliac Artery Aneurysm Repair

The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider MCG Guidelines.

Coverage Limitations

US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage