61642
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
8.66
Facility
$328.66
Non-Facility
$328.66
Key Coverage Criteria
- Extracranial Stent Placement with or without Angioplasty:
- Extracranial carotid artery stent placement with or without angioplasty is consideredmedically necessaryfor individuals who meet EITHER A or B of the following criteriaandcan be safely treated by this approachandwho have no angiographically visible intraluminal thrombus:
- Symptomatic stenosis equal to or greater than 50%,orasymptomatic stenosis equal to or greater than 80%;andOne ormoreof the following conditions which put the individual at a high risk or unsuitable for surgery:Congestive heart failure (NYHA Class III/IV) or left ventricular ejection fraction less than 30%;orOpen heart surgery needed within the next 6 weeks;orRecent myocardial infarction (greater than 24 hours and less than 4 weeks);orSevere chronic obstructive pulmonary disease;orUnstable angina [...]
- Congestive heart failure (NYHA Class III/IV) or left ventricular ejection fraction less than 30%;or
- Open heart surgery needed within the next 6 weeks;or
- Recent myocardial infarction (greater than 24 hours and less than 4 weeks);or
1 Active Policy
ANTHEM-CG-SURG-76 — CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
Related Codes
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