CurrentAetnaPolicy 0531

Balloon-Expandable Venous Stents

Defines Aetna's medical necessity criteria for placement of balloon-expandable venous stents, lists covered and not-covered indications, associated CPT/HCPCS/ICD-10 codes, background evidence, and policy history. This is part 1 of 2; content reflects only the provided portion.

Policy Summary

PayerAetna

PolicyBalloon-Expandable Venous Stents

Policy CodePolicy 0531

Change TypeNo material change

Effective DateAug 21, 2001

Next Review DateJun 13, 2024

Key ActionProvider must document the indication (one of the listed medically necessary diagnoses) for stent placement and whether initial thrombolysis or surgical thrombectomy was performed or considered.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes reported in this update.

10Listed covered indications

2Examples of experimental/not covered indications

2023Policy last reviewed (year)

2024Next review

Coverage Summary

This policy (Number: 0531) addresses the placement of balloon-expandable venous stents. It defines Aetna's medical necessity criteria for use of these stents, lists covered and not-covered indications, and includes associated CPT/HCPCS/ICD-10 codes, background evidence, and policy history. Coverage stance is mixed: stent placement is considered medically necessary for a set of specified venous indications (for example, Budd-Chiari syndrome, chronic iliac vein occlusions, ilio‑femoral thrombosis from iliac compression, post‑operative venous narrowing after sinus venosus ASD repair, pediatric pulmonary artery stenosis/hypoplasia, salvage of thrombosed/stenotic dialysis access grafts, superior/inferior vena cava stenosis, May‑Thurner syndrome, and venous baffle limb obstruction after Mustard/Senning repair), while stent use is experimental and investigational (not covered) for other indications such as management of central vein stenosis in hemodialysis individuals and porto‑mesenteric/porto‑systemic venous reconstruction due to insufficient evidence of effectiveness.

Medical-Necessity Criteria

Medical Necessity

Aetna considers placement of balloon-expandable venous stents with or without initial thrombolysis or surgical thrombectomy medically necessary for any of the following indications:

Medical Necessity criteria

Budd-Chiari syndrome (thrombotic obstruction of major hepatic veins).
Chronic iliac vein occlusions.
Chronic ilio-caval vein obstruction.
Ilio-femoral thrombosis secondary to iliac compression syndrome (compression of the left iliac vein between the right iliac artery and the fifth lumbar vertebra).
Post-operative venous narrowing due to repair of sinus venosus atrial septal defect (ASD).
Pulmonary artery stenosis and/or hypoplasia in a child.
Salvage of thrombosed or stenotic arterio-venous dialysis access grafts.
Superior or inferior vena caval stenosis in a child or adult.
Symptomatic pelvic venous spurs (May-Thurner syndrome) – left deep venous thrombosis or post-thrombotic leg swelling.
Venous obstruction of the superior or inferior limb of an atrial baffle after Mustard or Senning repair of transposition of the great arteries.

Experimental and Investigational (Not Covered)

Aetna considers balloon-expandable venous stents experimental and investigational for all other indications because of insufficient evidence of effectiveness. Examples include (not an all-inclusive list):

Experimental/Not Covered examples

Management of central vein stenosis in hemodialysis individuals.
Porto-mesenteric and porto-systemic venous reconstruction.

Coding

Covered CPT codes (if selection criteria met)CPTCovered

37248	Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein [not covered for porto-mesenteric and porto-systemic venous reconstruction].
37249	Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein (List separately in addition to code for primary procedure) [not covered for porto-mesenteric and porto-systemic venous reconstruction].

HCPCS codes (related to policy)HCPCS

C1874	Stent, coated/covered, with delivery system.
C1876	Stent, non-coated/non-covered, with delivery system.
C1877	Stent, non-coated/non-covered, without delivery system.
C2617	Stent, non-coronary, temporary, without delivery system.
C2623	Catheter, transluminal angioplasty, drug-coated, non-laser.
C2625	Stent, non-coronary, temporary, with delivery system.

ICD-10 codes covered (if selection criteria met)ICD-10Covered

I80.10 - I80.13	Phlebitis and thrombophlebitis of femoral vein (deep) (superficial) [ilio-femoral thrombosis secondary to iliac compression syndrome].
I80.201 - I80.209	Phlebitis and thrombophlebitis of other and unspecified deep vessels of lower extremities [May-Thurner syndrome].
I80.221 - I80.299	Phlebitis and thrombophlebitis of other and unspecified deep vessels of lower extremities [May-Thurner syndrome].
I80.211 - I80.219	Phlebitis and thrombophlebitis of iliac vein [chronic occlusions].
I82.0	Budd-Chiari syndrome.
I82.421 - I82.429	Acute embolism and thrombosis of iliac vein [iliofemoral thrombosis secondary to iliac compression syndrome].
I82.521 - I82.529	Chronic embolism and thrombosis of iliac vein [chronic iliac vein occlusions].
I87.1	Compression of vein [vena cava syndrome (inferior) (superior)] [chronic ilio-caval vein obstruction] [not covered for central vein stenosis in hemodialysis individuals].
Q20.5	Discordant atrioventricular connection [status post Mustard or Senning repair].
Q25.6	Stenosis of pulmonary artery.

1–10 of 16

1/2

ICD-10 codes not covered for indications listed in the CPBICD-10Not Covered

Z99.2

Dependence on renal dialysis [central vein stenosis in hemodialysis individuals].

Billing note for providers: Do not bill CPT 37248 or 37249 for porto‑mesenteric or porto‑systemic venous reconstruction—those CPT entries are explicitly noted as not covered for those reconstructions. Also, ICD‑10 Z99.2 (dependence on renal dialysis) is expressly listed as not covered for the CPB indication of central vein stenosis in hemodialysis individuals; providers should avoid using Z99.2 when billing for covered stenting indications and be aware that claims for stenting to manage central vein stenosis in hemodialysis patients are considered experimental and may be denied.

Provider Actions

Documentation Required

Document indication and prior procedures

Provider must document the indication (one of the listed medically necessary diagnoses) for stent placement and whether initial thrombolysis or surgical thrombectomy was performed or considered.

Denial Risk

Claims for experimental indications may be denied

Claims for balloon-expandable venous stents for indications considered experimental or investigational (for example, management of central vein stenosis in hemodialysis individuals and porto-mesenteric/porto-systemic venous reconstruction) are subject to denial due to insufficient evidence of effectiveness.

Billing Rule

Do not use listed CPT codes for excluded indications

CPT codes 37248 and 37249 are noted as not covered for porto-mesenteric and porto-systemic venous reconstruction; providers should not bill these codes for those indications.

37248
37249

Billing Rule

ICD-10 exclusion mapping

Do not use ICD-10 Z99.2 (dependence on renal dialysis) when billing for covered stenting indications as this ICD-10 is explicitly listed as not covered for the CPB indications (central vein stenosis in hemodialysis individuals).

Z99.2

Background & Evidence

Background: Endovascular balloon dilation and balloon‑expandable stents are used to re‑establish venous flow and relieve symptomatic venous obstructions; stents are especially useful for dilatable lesions with vessel recoil after angioplasty. Evidence and case series report high technical success and varying patency rates across indications (for example, ilio‑caval and ilio‑femoral reconstructions), but experience is limited in certain areas. Pulmonary vein stenosis dilation has had uniformly poor long‑term results in available reports. Data are also limited for pediatric porto‑mesenteric and porto‑systemic venous reconstruction, and for management of central vein stenosis in hemodialysis patients—these latter indications are cited as examples for which stent placement is considered experimental and investigational because of insufficient evidence of effectiveness.

Evidence / Outcomes (select examples)

Notes / Definitions / Limitations

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