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Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (AmeriHealth)
11.02.27n

Policy


This policy does not apply to members for whom the Carelon Medical Benefits Management program​​ is not applicable. This policy only applies to members for whom the program is applicable. Individual member benefits must be verified before/prior to providing services.​

The intent of this policy is to communicate that the Company has delegated the responsibility for utilization management activities for percutaneous coronary intervention, coronary angiography and arterial ultrasound to Carelon Medical Benefits Management. Percutaneous coronary intervention, coronary angiography and arterial ultrasound are considered not medically necessary when they are used for conditions that are not addressed in the Carelon Medical Benefits Management Clinical Appropriateness Guidelines.

Please refer to the References section of this policy for a link to the entire Carelon Medical Benefits Management Clinical Appropriateness Guidelines for percutaneous coronary intervention, diagnostic coronary angiography​ and arterial ultrasound that are part of the program. Note: Arterial ultrasound is addressed in the Carelon Medical Benefits Management Advanced Imaging Clinical Appropriateness Guidelines for Advanced Imaging-Vascular Imaging, which can be found under Carelon Medical Benefits Management​​ Radiology Guidelines. Refer to Attachment A of this policy for a complete list of codes for percutaneous coronary intervention, coronary angiography and arterial ultrasound services.

The Company has delegated the responsibility for utilization management activities for percutaneous coronary intervention, diagnostic coronary angiography and arterial ultrasound to Carelon Medical Benefits Management. In addition, Carelon Medical Benefits Management utilizes their Clinical Appropriateness Guidelines to determine the medical necessity for these services:

PERCUTANEOUS CORONARY INTERVENTION
  • Percutaneous transluminal coronary artery angioplasty
  • Percutaneous transcatheter intracoronary stent placement
  • Percutaneous transluminal coronary atherectomy
When percutaneous coronary intervention is part of another outpatient procedure, the percutaneous coronary intervention will be managed through Carelon Medical Benefits Management, irrespective of the utilization management requirements for the other outpatient procedure. Percutaneous coronary intervention services that are performed on an emergent basis are not part of the utilization management program.

Carelon Medical Benefits Management does not manage percutaneous transluminal coronary lithotripsy​ or percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon​ for the Company; please refer to Company medical policy #12.01.01 Experimental/Investigational Services. ​​​
DIAGNOSTIC CORONARY ANGIOGRAPHY

Diagnostic coronary angiography of native coronary arteries or bypass grafts, whether or not the angiographic procedure is performed in conjunction with right and/or left heart catheterization.

For computed tomography angiography (CTA) and coronary artery CTA (CCTA), refer to Carelon Medical Benefits Management​ ​​​Diagnostic Imaging Clinical Appropriateness Guidelines.

ARTERIAL ULTRASOUND 
  • Duplex ultrasound imaging of the aorta, inferior vena cava, and iliac vessels
  • Duplex ultrasound imaging of the extracranial arteries
  • Duplex ultrasound imaging of the arteries of the lower extremities
  • Duplex ultrasound imaging of the arteries of the upper extremities
  • Physiologic testing for peripheral arterial disease (PAD) of the upper and lower extremities*
*Physiologic testing includes the noninvasive evaluation of the peripheral circulation based on measurement of limb blood pressure with pulse volume recordings or Doppler waveforms, or other parameters without utilizing data from direct imaging of the blood vessels.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, percutaneous coronary intervention, coronary angiography and arterial ultrasound are covered under the medical benefits of the Company’s products when the medical necessity criteria for the services are met.

Description

The Company has delegated the responsibility of utilization management for percutaneous coronary intervention, coronary angiography and arterial ultrasound to Carelon Medical Benefits Management. Percutaneous coronary intervention services that are performed on an emergent basis are not part of the utilization management program. Carelon Medical Benefits Management​ uses its Clinical Appropriateness Guidelines to determine medical necessity for percutaneous coronary intervention, coronary angiography and arterial ultrasound, and to direct the application of these services for our members. Multiple sources were used to develop these guidelines, including technology assessments, peer-reviewed medical literature, clinical outcomes research, and consensus opinion in medical practice. The primary resources include:

  • American College of Radiology (ACR) Appropriateness Criteria
  • American Institute of Ultrasound Medicine (AIUM)
  • Society of Interventional Radiology
  • Society of Nuclear Medicine (SNM)
  • American College of Cardiology (ACC)​
  • American Heart Association (AHA)
  • American Heart Association Task Force (AHATF)
  • American Society of Nuclear Cardiology (ASNC)
  • American Society of Echocardiography (ASE)
  • American College of Cardiology Foundation (ACCF)
  • Heart Failure Society of America (HFSA)
  • Heart Rhythm Society (HRS)
  • Society of Cardiovascular Anesthesiologists
  • Society for Cardiovascular Angiography and Interventions (SCAI)
  • Society of Critical Care Medicine (SCCM)
  • Society of Cardiovascular Computed Tomography (SCCT)
  • Society for Cardiovascular Magnetic Resonance (SCMR)
  • Society for Vascular Medicine
  • Society for Vascular Surgery
  • Society of Thoracic Surgeons (STS)
  • American Association for Thoracic Surgery (AATS)
  • Agency for Healthcare Research and Quality (AHRQ)
  • Centers for Medicare & Medicaid Services (CMS)
  • National Guideline Clearinghouse

References

Carelon Medical Benefits Management. Clinical Appropriateness Guidelines: Diagnostic Coronary Angiography. [Carelon Web site]. 11/15/2025. Available at: Current Cardiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). [Proprietary]. Accessed February 16, 2026.

Carelon Medical Benefits Management. Clinical Appropriateness Guidelines: Percutaneous Coronary Intervention. [Carelon Web site]. 01/01/2026. Available at: Current Cardiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com)​. [Proprietary]. Accessed February 16, 2026.​

Carelon Medical Benefits Management®. Clinical Appropriateness Guidelines Advanced Imaging: Vascular Imaging. [Carelon  Web site]. 01/01/2026. Available at: Current Radiology Guidelines | Carelon Clinical Guidelines and Pathways (carelonmedicalbenefitsmanagement.com). Accessed February 16, 2026.

Department of Health and Human Services. Center for Medicare and Medicaid Services. Medicare Preventive Services. Quick Reference Information: Preventive Services. April 2024​. Available at: https://www.cms.gov/Medicare/Prevention/Prevn​tionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html. Accessed February 16, 2026.​
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Coding

CPT Procedure Code Number(s)
Refer to Attachment A for a list of procedure codes applicable to percutaneous coronary intervention, coronary angiography and arterial ultrasound.
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)

​See Attachment A.

Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

​Revisions From 11.02.27n:
04/01/2026
This version of the policy will be issued on 04/06/2026 with a retroactive effective date of 04/01/2026.

​​Carelon Medical Benefits Management has revised their Diagnostic Coronary Angiography Guideline​. For a detailed summary of changes, see the specific guidelines which will become effective 04/01/2026. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiovascular-guidelines/.

The following CPT codes have been added​ to Attachment A of this policy:
C7568, C7569, C7570​

Revisions From 11.02.27m:
01/01/2026This policy has been identified for the CPT code update, effective 01/01/2026.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following CPT codes have been terminated and removed from Attachment A of this policy:
92921, 92925, 92929, 92934, 92938, 92944
​

The following CPT codes have been added to Attachment A of this this policy:
92930, 92945


The following CPT codes have been revised in Attachment A of this this policy:
92920, 92924, 92928, 92933, 92937, 92943​

​Revisions From 11.02.27l:
11/15/2025
This version of the policy will become effective on 11/15/2025. 

Carelon Medical Benefits Management has revised their Advanced Imaging Clinical Appropriateness Guidelines Cardiology. For a detailed summary of changes, see the specific guidelines which will become effective 11/15/2025​. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiovascular-guidelines/. ​

Revisions From 11.02.27k:
03/24/2025
This version of the policy will become effective on 03/24/2025. 

The intent of this policy has not changed; however, a statement was added to refer to Company medical policy #12.01.01 Experimental/Investigational Services for percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon. ​​


Revisions From 11.02.27j:
01/01/2025​This policy has been identified for the CPT and HCPCS code update, effective 01/01/2025.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following HCPCS code has been termed and removed from Attachment A of this policy:
C7558​

The following HCPCS codes have been added to Attachment A of this this policy:
C7562, C7563​​

_______________________________

Addendum: On 01/14/2025, the following HCPCS code was removed from Attachment A of​ this policy because it was initially added in error:

C7563 Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery, initial artery and all additional arteries​

Revisions From 11.02.27i:
10/20/2024​This version of the policy will become effective on 10/20/2024.

Carelon Medical Benefits Management has revised their Clinical Appropriateness Guidelines Cardiology. For a detailed summary of changes, see the specific guidelines that will become effective on 10/20/2024​. These guidelines are available online at: https://guidelines.carelonmedicalbenefitsmanagement.com/current-cardiology-guidelines/​. ​​​

Please refer to Company medical policy #12.01.01 Experimental/Investigational Services for percutaneous transluminal coronary lithotripsy. ​

​Revisions From 11.02.27h:
01/02/2024​This policy has been identified for the HCPCS code update, effective 01/02/2024.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.​

The following HCPCS codes have been added to Attachment A of this this policy:
C7557, C7558​

Revisions From 11.02.27g:
​06/28/2023

​​The policy has been reviewed and reissued to communicate the Company's continuing position on percutaneous coronary intervention, coronary angiography and arterial ultrasound. 

The intent of the policy has not changed; however, AIM Specialty Health® has been revised to Carelon Medical Benefits Managemen​t.
01/01/2023​This policy has been identified for the CPT and HCPCS code update, effective 01/01/2023.

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

The following CPT code has been revised in Attachment A of this policy:
93568​

The following HCPCS codes have been added to Attachment A of this this policy:
C7516, C7517, C7518, C7519, C7520, C7521, C7522, C7523, C7524, C7525, C7526, C7527, C7528, C7529, C7533, C7552, C7553​

Revisions From 11.02.27f:
11/06/2022

This version of the policy will be issued on 12/05/2022 with a retro-effective date of 11/06/2022.​


AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Diagnostic Coronary Angiography . These guidelines will become effective 11/06/2022. Upon approval, these guidelines are available online http://www.aimspecialtyhealth.com/CG-Cardiology.html. ​


Revisions From 11.02.27e:​

​07/01/2022
​The policy has been reviewed and reissued to communicate the Company’s continuing position on Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (Independence)​. 

The intent of this policy remains unchanged, but the policy disclaimer has been revised to communicate:

This policy does not apply to Members for whom AIM Specialty Health® program​s​ is not applicable. This policy only applies to members for whom the Program is applicable. Individual member benefits must be verified before/prior to providing services.

03/13/2022

This version of the policy will become effective on 03/13/2022.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Diagnostic Coronary Angiography . These guidelines will become effective 03/13/2022. Upon approval, these guidelines are available online http://www.aimspecialtyhealth.com/CG-Cardiology.html. 


Revisions From 11.02.27d:

03/14/2021

This version of the policy will become effective on 03/14/2021.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Diagnostic Coronary Angiography . These guidelines will become effective 03/14/2021. Upon approval, these guidelines are available online http://www.aimspecialtyhealth.com/CG-Cardiology.html. 


The summary changes are as follows:

 

Diagnostic Coronary Angiography

Added criteria to specify appropriate scenarios in individuals with suspected congenital coronary artery anomalies.  ​


Revisions From 11.02.27c:
11/10/2019This version of the policy will become effective 11/10/2019.

The intent of this policy remains unchanged, but the policy has been updated to convey that Arterial Ultrasound is addressed in the AIM Specialty Health® (AIM) Advanced Imaging Clinical Appropriateness Guidelines for Advanced Imaging-Vascular Imaging, which can be found under AIM’s Radiology Guidelines. These guidelines are available online at: http://aimspecialtyhealth.com/CG-Radiology.html. Percutaneous Coronary Intervention and Coronary Angiography services remain under AIM's Cardiology Guidelines.

Revisions From 11.02.27b:
07/01/2019This version of the policy will become effective 07/01/2019.

AIM Specialty Health® (AIM) has revised their Clinical Appropriateness Guidelines for Arterial Ultrasound . These guidelines will become effective 07/01/2019. These guidelines are available online at: http://www.aimspecialtyhealth.com/CG-Cardiology.html.

Revisions From 11.02.27a:
05/01/2019This version of the policy will become effective 05/01/2019.

The following HCPCS codes have been added to Attachment A of this policy: C9600; C9601; C9602; C9603; C9604; C9605; C9607; C9608 [Medically Necessary].

Effective 10/05/2017 this policy has been updated to the new policy template format.
4/6/2026
4/6/2026
11.02.27
Medical Policy Bulletin
Commercial
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No