DESCRIPTION
Percutaneous transluminal angioplasty (PTA) is a procedure used to restore blood flow by opening arteries that have become stenosed (narrowed) or occluded (blocked) with an accumulation of fatty deposits. The goal of percutaneous transluminal angioplasty of the aortic arch vessels and coarctation of the aorta is the restoration of arterial blood flow by enlarging the lumen of a vessel stenosed or occluded by arteriosclerotic plaques or disease processes.
A stent is a tiny stainless steel cage that is inserted into the artery after angioplasty has been performed to help maintain patency of the artery. It may reduce the rate of restenosis. The individual may need to be on blood thinning medication to help prevent blood clots when stents are used.
POLICY
Percutaneous transluminal angioplasty with stenting of the carotid arteries is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Percutaneous transluminal angioplasty with or without stenting for the treatment of coarctation of the aorta is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Percutaneous transluminal angioplasty with or without stenting for the treatment of brachiocephalic and subclavian arteries is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Percutaneous transluminal angioplasty with or without stenting of the carotid arteries when not at high risk for adverse events from carotid enterectomy and for other conditions/diseases is considered investigational.
Percutaneous transluminal angioplasty with or without stenting for the treatment of coarctation of the aorta for other conditions/diseases is considered investigational.
Any stenting system and embolic protection device utilized for this procedure must have FDA approval specific to the indication, otherwise its use will be considered investigational.
Policies with similar titles: Angioplasty and/or Stenting for Intracranial Arterial Disease
MEDICAL APPROPRIATENESS
Percutaneous transluminal angioplasty is considered medically appropriate if ANY ONE of the following are met:
With stenting for the treatment of stenosed carotid arteries with ALL of the following:
ANY ONE of the following as evidenced by ultrasound or angiogram:
Presents with neurological symptoms and greater than or equal to 50% stenosis of the common or internal carotid artery
Presents without neurological symptoms and greater than or equal to 80% stenosis of the common or internal carotid artery
High risk for adverse events from carotid endarterectomy (e.g., congestive heart failure, abnormal stress test, need for open-heart surgery, severe pulmonary disease, contralateral carotid occlusion, contralateral laryngeal nerve palsy, previous radical neck surgery or radiation therapy to the neck, recurrent stenosis after endarterectomy, age greater than 80 years)
Reference vessel diameter within the range of 4.0 (millimeters) mm to 9.0 mm at the target lesion
With or without stenting for the treatment of coarctation of the aorta with ANY ONE of the following:
Angiographic evidence of significant discrete coarctation
Coarctation pressure gradient greater than or equal to 20 mm HG
Systemic hypertension not controlled by medical treatment
Inability to tolerate surgical correction
Recurrent coarctation following prior attempted surgery
Recurrent coarctation following surgical palliation of hypoplastic left heart syndrome, including surgical repair of the aortic arch
With or without stenting for the treatment of stenosed brachiocephalic and subclavian arteries with ALL of the following:
Stenosis greater than 50% and symptomatic
Myocardial ischemic symptoms when there is a patent ipsilateral internal mammary to coronary bypass
ANY ONE of the following:
Ischemic symptoms in the ipsilateral arm
There is greater than 10 mm Hg systolic pressure differential
Neurological symptoms of subclavian steal syndrome with ultrasound or radiographic evidence of reversal of flow in the ipsilateral artery
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.
ADDITIONAL INFORMATION
Carotid endarterectomy continues to be the gold standard for treatment of atherosclerotic occlusions of the carotid arteries.
No evidence of long-term efficacy is available from published studies regarding percutaneous transluminal angioplasty with or without stenting of the carotid arteries without high risk for carotid enterectomy, vertebral arteries, or for coarctation of the aorta for other conditions/diseases.
SOURCES
American Heart Association. (2009, May). Coarctation of the aorta (CoA). Retrieved September 16, 2009 from http://216.185.112.5/presenter.jhtml?identifier=1667.
BlueCross BlueShield Association. Medical Policy Reference Manual. (6:2008). Extracranial carotid angioplasty / stenting (7.01.68). Retrieved September 16, 2009 from BlueWeb. (36 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Medical Policy Reference Manual. (7:2008). Percutaneous transluminal angioplasty of intracranial atherosclerotic stenoses with or without stenting. (2.01.54). Retrieved September 16, 2009 from BlueWeb. (12 articles and/or guidelines reviewed)
Brountazos, E. N., Peterson, B., Binkert, C., Panagiotou, I., & Kaufman, J. A. (2004). Primary stenting of subclavian and innominate artery occlusive disease: A single center's experience. Cardiovascular and Interventional Radiology, 27 (6), 616-623. Abstract retrieved April 7, 2006 from PubMed database.
Cloud, G. C., Crawley, F., Clifton, A., McCabe, D. J., Brown, M. M., & Markus, H. S. (2003). Vertebral artery origin angioplasty and primary stenting: Safety and restenosis rates in a prospective series. Journal of Neurology, Neurosurgery and Psychiatry, 74 (5), 586-590. Abstract retrieved April 4, 2006 from PubMed database.
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, July). Percutaneous Transluminal Angioplasty (PTA) (NCD 20.7, p. 2-8, 2-10). The Ingenix Complete Guide to Medicare Coverage Issues.
De Vries, J. P., Jager, L. C., Van den Berg, J. C., Overtoom, T. T., Ackerstaff, R. G., Van de Pavoordt, E. D., et al. (2005). Durability of percutaneous transluminal angioplasty for obstructive lesions of proximal subclavian artery: Long-term results. Journal of Vascular Surgery, 41 (1), 19-23. Abstract retrieved June 28, 2006 from PubMed database.
Fawzy, M. E., Awad, M., Hassan, W., Kadhi, Y. A., Shoukri, M., & Fadley, F. (2004). Long-term outcome (up to 15 years) of balloon angioplasty of discrete native coarctation of the aorta in adolescents and adults. Journal of the American College of Cardiology, 43 (6), 1062-1067.
Harada, K. (2004). Therapeutic strategy and outcome of stenting for subclavian and innominate artery occlusive disease. No Shinkei Geka. Neurological Surgery, 32 (2), 151-158. Abstract retrieved April 4, 2006 from PubMed database.
Hauth, E. A., Gissler, H. M., Drescher, R., Jansen, C., Jaeger, H. J., & Mathias, K. D. (2004). Angioplasty or stenting of extra- and intracranial vertebral artery stenoses. Cardiovascular and Interventional Radiology, 27 (1), 51-57. Abstract retrieved April 7, 2006 from PubMed database.
Hayes. Medical Technology directory. (2006, September). Stent angioplasty for vertebral artery stenosis. Retrieved September 19, 2009 from www.HayesInc.com/subscribers. (28 articles and/or guidelines reviewed)
Hayes. Medical Technology directory. (2007, December). Carotid artery stenting for the treatment of carotid artery stenosis. Retrieved September 19, 2009 from www.HayesInc.com/subscribers. (100 articles and/or guidelines reviewed)
Janssens, E., Leclerc, X., Gautier, C., Godefroy, O., Koussa, M., Henon, H., et al. (2004). Percutaneous transluminal angioplasty of proximal vertebral artery stenosis: Long-term clinical follow-up of 16 consecutive patients. Neuroradiology, 46 (1), 81-84. Abstract retrieved April 7, 2006 from PubMed database.
Peterson, B. G., Resnick, S. A., Morasch, M. D., Hassoun, H. T., & Eskandari, M. K. (2006). Aortic arch vessel stenting: A single-center experience using cerebral protection. Archives of Surgery, 141 (6), 560-563. Abstract retrieved June 28, 2006 from PubMed database.
Przewlocki, T., Kablak-Ziembicka, A., Pieniazek, P., Musialek, P., Kadzielski, A., Zalewski, J., et al. (2006). Determinants of immediate and long-term results of subclavian and innominate artery angioplasty. Catheterization and Cardiovascular Interventions, 67 (4), 519-526. Abstract retrieved April 4, 2006 from PubMed database.
The Technology Evaluation Center (2007, June). Angioplasty and stenting of the cervical carotid artery with distal embolic protection of the cerebral circulation (Vol. 22, No. 1). Retrieved October 8, 2009 from http://www.bcbs.com/blueresources/tec/vols/22/22_01.pdf. (125 articles and/or guidelines reviewed)
U. S. Food and Drug Administration. (2004, August). Center for Devices and Radiological Health. Pre-market approval decisions for August 2004. Retrieved January 28, 2005 from http://www.fda.gov/cdrh/pdf4/p040012a.pdf.
Walhout, R. J., Lekkerkerker, J. C., Oron, G. H., Bennink, G. B., & Meijboom, E. J. (2004). Comparison of surgical repair with balloon angioplasty for native coarctation in patients from 3 months to 16 years of age. European Journal of Cardio-Thoracic Surgery, 25 (5), 722-727.
Yadav, J. S., Wholey, M. H., Kuntz, R. E., Fayad, P., Katzen, B. T., Mishkel, G. J., et al. (2004). Protected carotid-artery stenting versus endarterectomy in high-risk patient. The New England Journal of Medicine, 351 (15), 1493-1501.
Zoghbi, J., Serraf, A., Mohammadi, S., Belli, E., Gayet, F. L., Aupecie, B., et al. (2004). Is surgical intervention still indicated in recurrent aortic arch obstruction? The Journal of Thoracic and Cardiovascular Surgery, 127 (1), 203-212.
ORIGINAL EFFECTIVE DATE: 8/1983
MOST RECENT REVIEW DATE: 10/8/2009
ID_BT
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.
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