CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

This policy addresses stent placement with or without angioplasty in the extracranial carotid, vertebral, and intracranial arteries. Anthem covers extracranial carotid artery stenting/angioplasty when the individual has symptomatic stenosis ≥50% or asymptomatic stenosis ≥80%, can be safely treated by this approach, has no angiographically visible intraluminal thrombus, and is at high surgical risk for endarterectomy (e.g., NYHA III/IV heart failure or LVEF <30%, recent MI, severe COPD, unstable angina CCS III/IV, need for open-heart surgery within 6 weeks, inability to position the neck, or tracheostomy). Carotid stenting is not medically necessary when these criteria are not met (e.g., complete occlusion, symptomatic <50%, asymptomatic <80%), and stenting/angioplasty for vertebral or intracranial atherosclerotic disease is generally not covered due to insufficient evidence.

"Extracranial Stent Placement with or without Angioplasty:"