34203
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
17.41
Facility
$862.41
Non-Facility
$862.41
Documentation Required
- (Inferred) For coronary or peripheral arterial use: documentation of vessel diameter ≥2.0 mm and that AngioJet thrombectomy is being performed prior to angioplasty or stent placement (policy text: 'prior to angioplasty or stent placement').
- (Inferred) For lower-extremity DVT: clinical documentation showing failure of prior pharmacologic thrombolysis or documentation of contraindication to pharmacologic thrombolysis.
- (Inferred) Appropriate diagnostic imaging or angiographic evidence of thrombus (angiography, CT, duplex ultrasound) supporting the indication for thrombectomy.
- (Inferred) Procedure notes and coding to support use of an AngioJet catheter (e.g., HCPCS C1757) and the applicable CPT code(s) listed in the policy; linkage of performed procedure to a covered diagnosis code.
Key Coverage Criteria
- I82.401 - I82.4z9 Acute embolism and thrombosis of deep veins of lower extremity [deep vein thrombosis]
- N18.6 End stage renal disease
- N18.9 Chronic kidney disease, unspecified
- HCPCS code covered if selection criteria are met: C1757 Catheter, thrombectomy/embolectomy
- Aetna considers the AngioJet Rheolytic Thrombectomy System, also known as the Possis AngioJet Rapid Thrombectomy System, medically necessary for the following:
- For removing fresh blood clots from any of the following vessels:
1 Active Policy
AETNA-CPB-0568 — AngioJet Rheolytic Thrombectomy System
Related Codes
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