This version of the policy will become effective 12/30/2019.
The policy has been reviewed and reissued to communicate the Company’s continuing position on Endovascular Grafts for Abdominal Aortic Aneurysms (AAA), Aortic-Iliac Aneurysms, and Infrarenal Aortic Aneurysms. Clinical information updated to reiterate Experimental/Investigational position for the use of wireless endovascular pressure sensors.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
A52.01 Syphilitic aneurysm of aorta
I71.3 Abdominal aortic aneurysm, ruptured
I71.4 Abdominal aortic aneurysm, without rupture
I72.3 Aneurysm of iliac artery
Q25.43 Congenital aneurysm of aorta
S35.09xA Other injury of abdominal aorta, initial encounter
S35.09xD Other injury of abdominal aorta, subsequent encounter
S35.09xS Other injury of abdominal aorta, sequela
Policy: 12.01.01aw:Experimental/Investigational Services
The following ICD-10 CM code has been added to this policy: