Vascular Stenting CPT codes 37221 - 37235 - covered ICD codes

Coverage Indications, Limitations, and/or Medical Necessity

Vascular stenting of lower extremity arteries performed for clinically significant occlusive vascular disease will be considered medically reasonable and necessary for a patient under any of the following circumstances:
Primary therapy for common iliac artery stenosis and occlusions.
Primary therapy for external iliac artery stenoses and occlusions.
Primary therapy for femoral/popliteal arterial stenosis and occlusions.
Salvage therapy for common and external iliac arteries for a suboptimal or failed result from balloon dilation (e.g., persistent translesional gradient, residual diameter stenosis greater than 50%, or flow-limiting dissection).
Salvage therapy for femoral/popliteal arteries for a suboptimal or failed result from balloon dilation (e.g., persistent translesional gradient, residual diameter stenosis greater than 50%, or flow-limiting dissection).
Salvage therapy for tibial/peroneal arterial lesions for a suboptimal result from ballon dilation.


Limitations

Vascular stenting of lower extremity arteries is considered experimental and investigational for a patient under any of the following circumstances as the effectiveness has not been well established and/or is not recommended, and therefore, will not be considered medically reasonable and necessary:
Primary therapy for tibial/peroneal arterial stenosis and occlusions.
It is the expectation that for the covered indications of this policy, the utilized stent will have Food and Drug Administration (FDA) approval for that indication. ‘Off-label use’ of drug-eluting stents and polytetrafluoroethylene (PTFE)-covered stents are non-covered (given the FDA approved use as well as off-label use of such devices is a subject of on-going clinical trials). For the covered indications, a stent approved by the FDA may be covered for off-label use for which efficacy has been supported in peer-reviewed medical literature, given that there are no FDA-contraindications or warnings which have been demonstrated in this regard and given that its use has been a long standing standard of care (this statement is limited to vascular stents for lower extremity arteries as applied to this LCD).

Revenue Codes
Code Description
0320 Radiology - Diagnostic - General Classification
0320 Radiology - Diagnostic - General Classification
0321 Radiology - Diagnostic - Angiocardiography
0322 Radiology - Diagnostic - Arthrography
0323 Radiology - Diagnostic - Arteriography
0323 Radiology - Diagnostic - Arteriography
0324 Radiology - Diagnostic - Chest X-Ray
0329 Radiology - Diagnostic - Other Radiology - Diagnostic
0329 Radiology - Diagnostic - Other Radiology - Diagnostic
0340 Nuclear Medicine - General Classification
0342 Nuclear Medicine - Therapeutic
0349 Nuclear Medicine - Other Nuclear Medicine
0350 CT Scan - General Classification
0351 CT Scan - Head Scan
0352 CT Scan - Body Scan
0359 CT Scan - CT - Other
0402 Other Imaging Services - Ultrasound
0404 Other Imaging Services - Positron Emission Tomography
0409 Other Imaging Services - Other Imaging Services
0610 Magnetic Resonance Technology (MRT) - General Classification
0614 Magnetic Resonance Technology (MRT) - MRI - Other
0615 Magnetic Resonance Technology (MRT) - MRA - Head and Neck
0616 Magnetic Resonance Technology (MRT) - MRA - Lower Extremities
0618 Magnetic Resonance Technology (MRT) - MRA - Other
0619 Magnetic Resonance Technology (MRT) - Other MRT

CPT/HCPCS Codes

Group 1 Codes
37221 Iliac revasc w/stent
37223 Iliac revasc w/stent add-on
37226 Fem/popl revasc w/stent
37227 Fem/popl revasc stnt & ather
37230 Tib/per revasc w/stent
37231 Tib/per revasc stent & ather
37234 Revsc opn/prq tib/pero stent
37235 Tib/per revasc stnt & ather



ICD-10 Codes that Support Medical Necessity

I70.201 Unspecified atherosclerosis of native arteries of extremities, right leg
I70.202 Unspecified atherosclerosis of native arteries of extremities, left leg
I70.203 Unspecified atherosclerosis of native arteries of extremities, bilateral legs
I70.209 Unspecified atherosclerosis of native arteries of extremities, unspecified extremity
I70.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg
I70.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg
I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs
I70.219 Atherosclerosis of native arteries of extremities with intermittent claudication, unspecified extremity
I70.221 Atherosclerosis of native arteries of extremities with rest pain, right leg
I70.222 Atherosclerosis of native arteries of extremities with rest pain, left leg
I70.223 Atherosclerosis of native arteries of extremities with rest pain, bilateral legs
I70.229 Atherosclerosis of native arteries of extremities with rest pain, unspecified extremity
I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh
I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle
I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg
I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site
I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf
I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle
I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot
I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg
I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site
I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg
I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
I70.268 Atherosclerosis of native arteries of extremities with gangrene, other extremity
I70.269 Atherosclerosis of native arteries of extremities with gangrene, unspecified extremity
I73.9 Peripheral vascular disease, unspecified
I74.3 Embolism and thrombosis of arteries of the lower extremities
I74.5 Embolism and thrombosis of iliac artery
I74.8 Embolism and thrombosis of other arteries
I77.1 Stricture of artery
I77.72 Dissection of iliac artery
T81.718A Complication of other artery following a procedure, not elsewhere classified, initial encounter
T81.718D Complication of other artery following a procedure, not elsewhere classified, subsequent encounter
T81.718S Complication of other artery following a procedure, not elsewhere classified, sequela
T81.719A Complication of unspecified artery following a procedure, not elsewhere classified, initial encounter
T81.719D Complication of unspecified artery following a procedure, not elsewhere classified, subsequent encounter
T81.719S Complication of unspecified artery following a procedure, not elsewhere classified, sequela