J3246 — Injection, tirofiban hcl, 0.25 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Imaging evidence documenting a salvageable tissue penumbra (e.g., advanced imaging such as CT perfusion demonstrating salvageable tissue) when endovascular stent retriever therapy is being considered: 'evidence of salvageable tissue on imaging' (explicit requirement in medical necessity statement).
- Imaging/angiographic documentation of occlusion of the anterior circulation (middle cerebral artery trunk or its branches or internal carotid artery) when seeking coverage for endovascular stent retriever therapy.
- Documentation of time of stroke symptom onset and that retrieval was performed within 12 hours after stroke onset (to meet the coverage time-window stated).
- For intra-arterial infusion of spasmolytics or calcium-channel blockers for vasospasm: documentation that the patient has medically refractory symptomatic delayed cerebral ischemia (cerebral vasospasm) after aneurysmal subarachnoid hemorrhage and that vasospasm is refractory to maximal medical management (e.g., induced hypertension and hypervolemia and administration of calcium channel antagonists) prior to endovascular therapy.
Key Coverage Criteria
- Intraarterial infusion of spasmolytics (e.g., papaverine) or calcium-channel blockers (e.g., nicardipine) into the intracranial arteries for the treatment of medically refractory symptomatic delayed cerebral ischemia (cerebral vasospasm) after aneurysmal subarachnoid hemorrhage.
- CPT codes covered if selection criteria are met: 37184 (primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel), 37185 (second and all subsequent vessel(s) within the same vascular family), and 61645 (percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnost [...]
- ICD-10 codes covered if selection criteria are met: I63.00 - I63.9 (cerebral infarction [acute ischemic stroke]); I67.82 (cerebral ischemia [medically refractory symptomatic delayed cerebral ischemia]); I67.841 - I67.848 (cerebral vasospasm and vasoconstriction [medically refractory symptomatic delayed cerebral ischemia]).
- Mechanical thrombectomy is beneficial for select patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion in the anterior circulation. (UpToDate cited: "Mechanical thrombectomy is beneficial for select patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion in the anterior circulation")
- Endovascular interventions for vertebrobasilar occlusions, including mechanical thrombectomy, may be treatment options at stroke centers with appropriate expertise. (UpToDate cited: "However, endovascular interventions for vertebrobasilar occlusions, including mechanical thrombectomy, may be treatment options [at] stroke centers with appropriate expertise.")
- PTAS (percutaneous transluminal angioplasty and stenting) for basilar artery stenosis: indicated in severe ("greater than or equal to 50 % to 70 %"), symptomatic basilar artery stenosis refractory to dual antiplatelet therapy. (Palmisciano et al. statement: "PTAS for BAS was indicated in severe (greater than or equal to 50 % to 70 %), symptomatic BAS refractory to dual anti-platelet therapy.")
1 Active Policy
AETNA-CPB-0789 — Acute Ischemic Stroke Treatments
Related Codes
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