C1874 — Stent, coated/covered, with delivery system
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- For EC-IC bypass with parent artery occlusion: results of balloon test occlusion when performed to assess ischemic tolerance, pre-operative hemodynamic assessments (CBF/CBV/OEF or equivalent) when used for hemodynamic failure, and operative reports specifying bypass type (high-flow vs low-flow, graft used).
- Peri-procedural and follow-up outcome documentation: NIH Stroke Scale (NIHSS), modified Rankin Scale (mRS) scores, procedural complications (stroke, intracerebral hemorrhage, death), and imaging follow-up (to assess occlusion, graft/stent patency, re-stenosis or re-canalization).
- No documentation requirements are present in the provided document text.
- Degree of carotid artery stenosis should be measured by duplex Doppler ultrasound or carotid artery angiography and recorded in the patient medical records.
Key Coverage Criteria
- First-stenting-without-retrieval (FRESH) technique (e.g., Solitaire FR first stenting) as a therapeutic option for ICAS-related emergent large vessel occlusion (single-center retrospective data showed favorable outcomes) (Kim et al 2021).
- Extracranial-intracranial (EC-IC) bypass surgery for cerebral revascularization when parent vessel occlusion (for aneurysm treatment) cannot be tolerated or where revascularization is needed (e.g., complex/giant intracranial aneurysms, hemodynamic failure secondary to athero-occlusive disease) (Schaller 2008; Garrett et al 2009; Dubovoy et al 2017; Ishishita et al 2014; Zhang et al 2021).
- High-flow EC-IC saphenous vein bypass grafting for treatment of complex intracranial aneurysms when indicated (retrospective series showing high graft patency and adequate cerebral blood flow) (Zhang et al 2021).
- No coverage indications or clinical coverage criteria are present in the provided document text.
- Percutaneous transluminal angioplasty of the extra-cranial carotid arteries, with or without stent implantation and embolic protection, in symptomatic individuals with at least 50 % stenosis of the carotid artery.
- TCAR as a treatment option for high-risk carotid stenosis patients (Kashyap et al: "initial positive data with TCAR indicated that it may be an attractive alternative to trans-femoral carotid artery stenting and possibly CEA for high-risk patients").
5 Active Policies
AETNA-CPB-0276 — Angioplasty and Stenting of Extra-Cranial and Intra-Cranial Arteries
AETNA-CPB-0621 — Drug-Eluting Stents
AETNA-CPB-0625 — Dysphagia Therapy
ANTHEM-SURG.00132 — SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency
CARELON-percutaneous-coronary-intervention-2023-06-18 — Percutaneous Coronary Intervention
Related Codes
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