Intravascular Ultrasound (IVUS) Imaging of Coronary Arteries
DESCRIPTION
Transcatheter intravascular ultrasound (IVUS) imaging utilizes a miniature ultrasound transducer mounted on the tip of a catheter and inserted directly into an artery or vein. This technique produces either two-dimensional tomographic images or three-dimensional computer-assisted reconstructions of planar IVUS images. Applications of IVUS include use as an adjunct to angioplasty, atherectomy, and placement of a stent.
POLICY
Intravascular ultrasound (IVUS) for the imaging of coronary arteries is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Intravascular ultrasound (IVUS) for the imaging of coronary arteries is considered medically appropriate if ANY ONE of the following criteria are met:
Evaluation of coronary obstruction at a location difficult to image by angiography in an individual with a suspected flow-limiting stenosis
Assessment of a suboptimal angiographic result after coronary intervention
Diagnosis of coronary disease after cardiac transplantation
Assessment of the adequacy of deployment of coronary stent, including the extent of stent apposition and determination of the minimum luminal diameter within the stent
Determination of plaque location and circumferential distribution for guidance of directional coronary atherectomy
Determination of the mechanism of stent restenosis (inadequate expansion versus neointimal proliferation) and to enable selection of appropriate therapy (plague ablation versus repeat balloon expansion)
Establish presence and distribution of coronary calcium in an individual for whom adjunctive rotational arthrectomy is contemplated
Determine extent of arthrosclerosis in individual with characteristic anginal symptoms and a positive functional study with no focal stenoses or mild CAD on angiography
Pre-interventional assessment of lesional characteristics as a means to select an optimal revascularization device
When angiographic diagnosis is not clear
When interventional treatment is planned
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
American College of Cardiology. (2001). American College of Cardiology clinical expert consensus document on standards for acquisition, measurement and reporting of intravascular ultrasound studies (IVUS). Retrieved November 7, 2011 from http://content.onlinejacc.org/cgi/reprint/37/5/1478.pdf.
American College of Cardiology. (2007). 2007 Focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention. Retrieved November 7, 2011 from http://content.onlinejacc.org/cgi/reprint/51/2/172.pdf.
American College of Cardiology. (2005). ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI writing committee to update the 2001 guidelines for percutaneous coronary intervention. Retrieved November 7, 2011 from http://content.onlinejacc.org/cgi/reprint/47/1/e1.pdf.
BlueCross BlueShield Association, Medical Policy Reference Manual. (4:2003). Intravascular ultrasound imaging of coronary arteries (6.01.04). Retrieved November 7, 2011 from BlueWeb.
ORIGINAL EFFECTIVE DATE: 10/1/2000
MOST RECENT REVIEW DATE: 12/8/2011
ID_BA
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.