Peripheral Vascular Intervention Guidelines

EviCore authorizes peripheral vascular interventions only when strict, objective indications are met (e.g., aneurysm size thresholds, NASCET stenosis criteria for carotid CEA/CAS, vertebral stenosis ≥60% with symptoms, venous perforator reflux ≥500 ms and ≥3.5 mm) and explicitly excludes many procedures (e.g., intracranial atherosclerosis treatment, routine infrapopliteal stenting, intravascular lithotripsy, prophylactic May‑Thurner stenting, primary renal vein stenting for Nutcracker). Prior authorization requires recent (≤6 months) in‑person clinical evaluation and imaging reports, documentation of symptoms and failed conservative therapy where applicable, specific procedural coding/measurements, and allows urgent/emergent exceptions with supporting documentation.

"Endovascular treatment of intracerebral pathology is indicated when there is documentation of any of the following: Unruptured Aneurysms: Treatment is indicated at >5 mm"