Endovascular Therapies for Extracranial Vertebral Artery Disease

This policy addresses endovascular therapies—including percutaneous transluminal angioplasty (with or without stenting), stent placement, and coil embolization, and select HDE intracranial stent systems—for extracranial vertebral artery disease (atherosclerotic stenosis, dissection, aneurysm) causing vertebrobasilar ischemia or when medical therapy or open surgical revascularization is ineffective or unsuitable. Major limitations: the policy characterizes endovascular treatment for extracranial vertebral disease as experimental/investigational and not covered, notes no devices are FDA‑approved specifically for this indication, limits HDE device use to their labeled intracranial indications (e.g., ≥50% stenosis and vessel size/access criteria), and states coverage is subject to the member’s benefit plan (policy is inactive).

"Extracranial vertebral artery disease (atherosclerotic stenosis, dissection, aneurysm) causing ischemia of the posterior (vertebrobasilar) cerebral circulation."