Endovascular Stent Grafts for Disorders of the Thoracic Aorta

This policy covers endovascular stent graft repair (TEVAR) of the descending thoracic aorta for conditions such as descending thoracic aortic aneurysms, acute complicated type B dissections (e.g., malperfusion, rupture), traumatic aortic tears, and selected uncomplicated type B dissections with high‑risk features. Coverage is limited to FDA‑approved devices used within device‑specific anatomic and sizing criteria (e.g., adequate proximal/distal nonaneurysmal landing zones and device diameter ranges such as Gore TAG 23–37 mm with ≥2 cm seals or Zenith TX2 24–38 mm with ≥25 mm seals), excludes ascending/arch disease and non‑FDA/off‑label uses, and generally favors medical management for most uncomplicated type B dissections unless high‑risk criteria are met.

"Descending thoracic aortic aneurysms treated per FDA‑approved device specifications"

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