37289
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
4.75
Facility
$214.77
Non-Facility
$921.53
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews.
- Documentation that conservative therapies were tried and failed, including: at least 12 weeks of Supervised Exercise Therapy or a Structured Community-Based Exercise Program; and pharmacologic therapy (e.g., lipid lowering therapy, antihypertensive therapy, antiplatelet therapy, and/or anticoagulants); and smoking cessation counseling/efforts if applicable.
- Documentation of impaired ability to work and/or perform activities of daily living (ADL) attributable to Claudication.
- Objective perfusion testing showing Ischemic peripheral artery disease with Ankle-Brachial Index (ABI) ≤ 0.90 (ABI < 0.90 indicates PAD).
Key Coverage Criteria
- Endovascular revascularization procedures (e.g., stents, angioplasty, and/or atherectomy) are proven and medically necessary for treating non-limb-threatening lower extremity ischemia in individuals with Claudication due to atherosclerotic disease of the aortoiliac and/or femoropopliteal arteries when all the following criteria are met: - Impaired ability to work and/or perform activities of daily living (ADL); and - All the following conservative therapies have been tried and failed: - At least [...]
- Endovascular revascularization procedures (e.g., stents, angioplasty, and/or atherectomy) are proven and medically necessary for treating Chronic Limb Threatening Ischemia (CLTI) with the diagnoses listed under Applicable Codes.
4 Active Policies
CARELON-endovascular-revascularization-2025-11-15-updated-2026-01-01 — Endovascular Revascularization
UHC-POL-lower-endovascular-procedures — Lower Extremity Endovascular Procedures
UMR-POL-UMR-lower-endovascular-procedures — Lower Extremity Endovascular Procedures
SUREST-POL-SUREST-lower-endovascular-procedures — Lower Extremity Endovascular Procedures
Related Codes
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