Does 37243 require prior authorization?

Yes, 37243 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 37243?

Medicare facility rate: $482.31. Non-facility rate: $7995.17. Work RVU: 11.45.

Verity

`37243`

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

11.45

Facility

$482.31

Non-Facility

$7995.17

Documentation Required

Document the clinical decision-making process for choosing endovascular versus open or hybrid revascularization, oriented to patient-centered goals.
Document the availability of autologous vein conduit, preferably a >3 mm single-segment great saphenous vein, when relevant to revascularization planning.
Document coronary artery disease status (symptomatic or asymptomatic).
Document chronic obstructive pulmonary disease status and oxygen dependence if present.

Key Coverage Criteria

Endovascular revascularization is appropriate when the individualized, patient-centered clinical decision favors endovascular over open or hybrid revascularization for peripheral arterial disease of the upper or lower extremities.
Anatomically less-complex lesions in patients with claudication or chronic limb-threatening ischemia (CLTI) are typically treated with an endovascular approach.
Endovascular revascularization of symptomatic upper extremity (UE) arterial disease is covered for threatened UE perfusion, coronary-subclavian steal syndrome with significant cardiac symptoms, embolization from the lesion, preservation or creation of hemodialysis access, or traumatic arterial injury disrupting peripheral arterial flow.
Endovascular revascularization for UE asymptomatic disease is covered only when required for the safety, feasibility, or effectiveness of another procedure (e.g., planned CABG with intended internal mammary artery use) or to support hemodialysis access creation/preservation.
Ankle-brachial index (ABI) ≤0.9 is diagnostic for lower extremity (LE) PAD and supports consideration of endovascular revascularization in symptomatic patients.
For claudication, endovascular revascularization is covered when all of the following are met: functionally limiting claudication causing inability to perform normal work/activities important to the patient; documented failure of guideline-directed medical therapy (GDMT) including statin, antiplatelet, and ACE inhibitor/ARB if hypertensive; inadequate response or not predicted to respond to exercise rehabilitation/pharmacologic therapy; lesion anatomy permits low-risk intervention with >50% like [...]

20 Active Policies

AETNA-CPB-0079 — Benign Prostatic Hyperplasia

AETNA-CPB-0274 — Ablation of Hepatic Lesions

A60246 — Billing and Coding: Endovascular Management for Peripheral Arterial Disease of the Upper and Lower Extremities

L40227 — Endovascular Management for Peripheral Arterial Disease of the Upper and Lower Extremities

CARELON-vascular-embolization-occlusion-2024-11-01 — Vascular Embolization Occlusion

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37243