61624
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
19.50
Facility
$1044.78
Non-Facility
$1044.78
Documentation Required
- For IVL or other device use in trials or registries: documentation of exclusion criteria (e.g., unprotected left main, extreme vessel tortuosity, true bifurcation lesions) or justification if used outside trial‑like populations.
- Follow‑up documentation: angiographic or clinical follow‑up data demonstrating target lesion revascularization, myocardial infarction, and major adverse cardiac events where applicable (studies cited report 6–24 month outcomes).
- When billing under the listed covered CPT/HCPCS/ICD-10 codes: medical record documentation supporting the billed diagnosis code(s) from the 'ICD-10 codes covered if selection criteria are met' list.
- No explicit "Documentation Requirements" section is provided in the CPB. (Inferred requirements below are based on the policy context and the 'selection criteria' language.)
Key Coverage Criteria
- Abciximab for patients with unstable angina not responding to conventional medical therapy when percutaneous coronary intervention is planned within 24 hours (FDA‑labeled indication).
- ICD-10 diagnoses covered if selection criteria are met: Z95.1 — "Presence of aortocoronary bypass graft"; Z95.5 — "Presence of coronary angioplasty implant and graft"; Z98.61 — "Coronary angioplasty status".
- Intracoronary gamma-radiation (Cordis Checkmate System) — delivery of therapeutic doses of gamma radiation for the purpose of reducing in‑stent restenosis in native coronary arteries (device for use in native coronary arteries 2.75 to 4.0 mm in diameter and lesions up to and including 45 mm in length) in stents that have been implanted in the past and have re‑stenosed.
- Intracoronary beta-radiation (Novoste Beta‑Cath System) — delivery of beta radiation to the site of successful percutaneous coronary intervention for the treatment of in‑stent restenosis in native coronary arteries with discrete lesions (treatable with a 20 mm balloon) in reference vessel diameter range 2.7 mm to 4.0 mm (FDA indication).
- Intracoronary brachytherapy for in‑stent restenosis in saphenous vein grafts (supported by randomized SVC‑WRIST Trial results showing reduced restenosis and target lesion revascularization).
- Abciximab (glycoprotein IIb/IIIa receptor antagonist) as an adjunct to percutaneous coronary interventions to prevent cardiac ischemic complications (FDA‑labeled indication).
2 Active Policies
AETNA-CPB-0491 — Coronary Artery Brachytherapy and Other Adjuncts to Coronary Interventions
ANTHEM-CG-SURG-76 — CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
Related Codes
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