M0301 — Fabric wrapping of abdominal aneurysm
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
- For aortic coarctation interventions: documentation of systemic arterial hypertension and resting arm–leg translesional pressure gradient >20 mm Hg (Hatoum et al, 2020; Rossi et al, 2020).
- For TEVAR/complex repair when considering celiac artery coverage: documentation demonstrating adequate visceral collateral pathways prior to coverage (Argyriou et al, 2022).
- For CSF drainage: documentation of rationale for pre-operative drain placement, procedural technical details of catheter insertion, target drainage pressure protocol (reported protocols commonly targeted intra-/post-operative pressures between 8 and 12 mm Hg), and monitoring/complication logs (Malloy et al, 2020; Suarez-Pierre et al, 2019).
- Pre-procedure imaging and sizing: documentation of pre-procedure CT angiography (CTA) or other imaging used for "pre-procedure sizing and device selection" (codes descriptions repeatedly reference pre-procedure sizing and device selection).
Key Coverage Criteria
- Computed tomography (CT) surveillance after endovascular (stent) aortic repair at 1 month, 6 months, and 12 months following repair, then every year.
- Endovascular repair of infra-renal abdominal aortic or aorto-iliac aneurysms with a Food and Drug Administration (FDA)-approved fenestrated, branched or non-fenestrated endovascular stent graft;
- Endovascular repair of descending thoracic aortic aneurysms with an FDA-approved endoprosthesis;
- Endovascular stenting (with a FDA-approved stent) for the treatment of aortic coarctation in persons with body weight of 25 kg (55 lbs) or more, and who exhibits systemic arterial hypertension and resting arm-leg pressure gradient of greater than 20 mmHg;
- FEVAR indicated as an option for high-risk patients when open repair is not suitable (Rao et al, 2015; Ou et al, 2015).
- FEVAR and chimney/endovascular (CH-EVAR) techniques as options for juxtarenal and short-neck AAAs (Li et al 2016; Ou et al 2015).
1 Active Policy
AETNA-CPB-0651 — Endovascular Repair of Aortic Diseases
Related Codes
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