CG-SURG-115 Mechanical Embolectomy for Treatment of Stroke

This policy addresses intra-arterial mechanical embolectomy (mechanical thrombectomy) for acute ischemic stroke. It is medically necessary for occlusions of the anterior cerebral artery (A1/A2), middle cerebral artery (M1/M2), or intracranial internal carotid artery when performed within 6 hours of symptom onset, with NIH Stroke Scale (NIHSS) ≥2, and neuroimaging excludes intracranial hemorrhage or arterial dissection. It is not medically necessary in all other circumstances when these criteria are not met.

"Intra-arterial mechanical embolectomy or thrombectomy is consideredmedically necessaryin the treatment of ischemic stroke whenanyof the following criteria sets (I, II, III, IVorV) have been met:"

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