CurrentAlliance HealthPolicy 1A-21

Endovascular Repair of Aortic Aneurysm

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Medicaid coverage policy for endovascular stent graft repair of abdominal and descending thoracic aortic aneurysms for NC Medicaid beneficiaries, describing medical necessity criteria, exclusions, and prior-approval considerations.

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CurrentAlliance HealthPolicy 1A-21

Endovascular Repair of Aortic Aneurysm

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Policy Summary

PayerAlliance Health

PolicyEndovascular Repair of Aortic Aneurysm

Policy CodePolicy 1A-21

Change TypeNo material changes

Effective DateAmended April 15, 2024

Last ReviewApr 15, 2024

Next Review DateN/A

Key ActionVerify Medicaid eligibility and document criteria (size, anatomy, device approval, and surgical risk) before submitting a claim.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 cmAAA diameter threshold

4–5 cm +0.5 cm/6moAAA growth criterion

23–37 mmThoracic diameter range

No PAPrior approval stance

NCApplicable state

Medical Necessity and Coverage Criteria

Abdominal Aortic Aneurysm

Covered when ALL of the following are met:

AAA Endovascular Repair Medical Necessity

High rupture risk: A. An aneurysmal diameter greater than 5 cm. B. An aneurysmal diameter of 4 cm–5 cm that has increased in size by 0.5 cm in the last six months. C. An aneurysmal diameter that measures twice the size of the normal infrarenal aorta.

Thoracic Aortic Aneurysm

Covered when ALL of the following are met:

DTA Endovascular Repair Medical Necessity: 1. The endoprosthesis is FDA approved for the treatment of descending thoracic aortic aneurysm; 2. The risks of an open repair of the aneurysm are unacceptable; 3. There is adequate iliac/femoral access; 4. Aortic inner diameter in the range of 23 mm to 37 mm; and 5. Two centimeters or greater non-aneurysmal aorta proximal and distal to the aneurysm.

All five items (1–5) must be met for coverage.

General Not Covered Criteria

Coverage is conditional; general non-coverage and limitations are stated as follows.

General coverage exclusions: Do not cover when any of the following apply: beneficiary does not meet Section 2.0 eligibility; beneficiary does not meet the clinical criteria in Section 3.0; the procedure duplicates another provider's procedure; or the procedure is experimental, investigational, or part of a clinical trial.

Refer to Sections 2.0 and 3.0 for specifics.

Prior Approval and Service Limits

Administrative coverage rules and limits.

Administrative coverage rules: Prior approval is not required for endovascular repair of aortic aneurysm. Medicaid covers only one procedure per date of service.1 procedure per date of service

EPSDT exceptions may apply for beneficiaries under age 21 as noted elsewhere in the policy.

The procedure is not covered when any of the following apply: the beneficiary does not meet the eligibility requirements in Section 2.0; the beneficiary does not meet the clinical criteria in Section 3.0; the service duplicates another provider’s procedure, product, or service; or the procedure, product, or service is experimental, investigational, or part of a clinical trial.

General exclusions include failure to meet Section 2.0 eligibility, failure to meet Section 3.0 clinical criteria, services that duplicate another provider’s service, and services that are experimental, investigational, or part of a clinical trial. The policy identifies None Apply for additional specific Medicaid exclusions in Sections 4.2.1 and 4.2.2.

When extension placement is performed to extend the repair to cover the left subclavian origin, do not report CPT codes 33881 or 33883; instead report only 33880 for that repair.

Do not report CPT code 33886 in conjunction with 33880 or 33881. Additionally, report 33886 only once regardless of the number of modules deployed.

Do not report CPT code 33889 in conjunction with CPT code 35694.

Do not report CPT code 33891 in conjunction with CPT code 35509 or CPT code 35601.

All balloon angioplasty and/or stent deployment within the target treatment zone for the endoprosthesis, whether performed before or after endograft deployment, are included in the endovascular graft procedure codes and are not reported separately.

Specific criteria covered by Medicaid: None Apply. There are no additional special Medicaid-covered criteria beyond those specified in the policy’s coverage criteria sections.

Services that are experimental, investigational, or provided as part of a clinical trial are not covered under this policy.

Codes and Coding Guidance

Removed CPT CodesCPT

34800	CPT removed (no longer valid as of 12/31/2017)
34826	CPT removed (no longer valid as of 12/31/2017)
34805	CPT removed (no longer valid as of 12/31/2017)
34808	CPT removed (no longer valid as of 12/31/2017)
34825	CPT removed (no longer valid as of 12/31/2017)
34900	CPT removed (no longer valid as of 12/31/2017)

Primary Endovascular Aortic Repair CPT CodesCPTCovered

33880	Endovascular repair of aortic aneurysm (part of 33880-33891 family)
33881	Endovascular repair (see pairing/limitations)
33883	Endovascular repair (see pairing/limitations)
33884	Endovascular repair (see pairing/limitations)
33886	Endovascular repair (module deployment — report once regardless of number of modules)
33889	Endovascular repair (do not report in conjunction with 35694)
33891	Endovascular repair (do not report in conjunction with 35509, 35601)

Radiology Supervision & Interpretation PairingsCPTCovered

75956	Radiological supervision and interpretation in conjunction with 33880
75957	Radiological supervision and interpretation in conjunction with 33881
75958	Radiological supervision and interpretation in conjunction with 33883-33884
75959	Radiological supervision and interpretation in conjunction with 33886

Separately reportable and mutually exclusive codesCPT

34812	Reported separately when applicable
34820	Reported separately when applicable; do not report 34833 in addition to 34820
34833	Reported separately when applicable; do not report in addition to 34820
34834	Reported separately when applicable
34844	Reported separately when appropriate
35226	Reported separately when applicable
35286	Component mapping to other codes as noted
36140	May be reported per mapping note
36200-36218	May be reported per mapping note
36245-36248	May be reported per mapping note

1–10 of 13

1/2

Aneurysm size and anatomic thresholds

Abdominal aortic aneurysm — diameter thresholdAneurysmal diameter greater than 5 cm indicates high rupture risk

Abdominal aortic aneurysm — growth criterionAneurysmal diameter 4–5 cm with increase of 0.5 cm within the last 6 months indicates high rupture risk

Abdominal aortic aneurysm — relative sizeAneurysmal diameter that measures twice the size of the normal infrarenal aorta indicates high rupture risk

Thoracic aortic aneurysm — graft sizingAortic inner diameter must be in the range of 23 mm to 37 mm for endovascular repair

Thoracic aortic aneurysm — landing zonesAt least 2 cm of non-aneurysmal aorta required proximal and distal to the aneurysm (landing zones)

Provider Responsibilities, Prior Approval, and Billing

Prior Authorization

Prior Authorization Required

Prior approval is not required for endovascular repair of aortic aneurysm under this Medicaid policy. However, when prior approval is required by other policies or for related services, providers must follow NCTracks prior-approval procedures and EPSDT guidance. Providers should verify that any required prior approval is obtained before performing services that are subject to prior authorization rules.

Medicaid does not require prior approval for endovascular repair of aortic aneurysm.
Verify eligibility and any other service-specific prior authorization requirements at each visit via NCTracks.
EPSDT does not waive prior approval requirements when applicable.

Billing Rule

Clinical Background

Aortic aneurysms most commonly occur in the abdominal aorta; thoracic aneurysms are less common. Endovascular stent grafting is a minimally invasive alternative to open surgical repair intended to reduce morbidity and mortality in high‑risk patients. Standard treatment for many thoracic aneurysms remains open surgical repair, with endovascular repair offered when the policy’s specified criteria are met.

Definitions

DefinitionsNone Apply

Policy Summary

PayerAlliance Health

PolicyEndovascular Repair of Aortic Aneurysm

Policy CodePolicy 1A-21

Change TypeNo material changes

Effective DateAmended April 15, 2024

Last ReviewApr 15, 2024

Next Review DateN/A

Key ActionVerify Medicaid eligibility and document criteria (size, anatomy, device approval, and surgical risk) before submitting a claim.

SourceLink

On This Page

Billing and Rate References

Providers shall bill their usual and customary charges and follow the NC Medicaid schedule of rates and billing guidance available through NCTracks and the Medicaid website. Refer to the NCTracks Provider Claims and Billing Assistance Guide and applicable Medicaid bulletins for claim submission rules and rate schedules.

Bill usual and customary charges.
For a schedule of rates, refer to https://medicaid.ncdhhs.gov/ and NCTracks guidance.
Submit professional claims on CMS-1500 and institutional claims on UB-04 as directed.

Denial Risk

Claims Denial Triggers

Claims may be denied if the beneficiary does not meet eligibility or the coverage criteria, if the service duplicates another provider's service, or if the service is experimental, investigational, or part of a clinical trial. Providers should confirm beneficiary eligibility and that all clinical criteria are met prior to submitting claims.

Denial triggers include: beneficiary not meeting Section 2.0 eligibility, not meeting Section 3.0 clinical criteria, duplicate services, or services that are experimental/investigational.
Verify eligibility at each service and document that coverage criteria are met.

Documentation Required

Claims and Coding Documentation Requirements

Claims must follow NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies. Use the required claim forms and formats and comply with national coding guidelines.

Follow NCTracks Provider Claims and Billing Assistance Guide and Medicaid bulletins for claim submission.
Professional claims: CMS-1500 / 837P. Institutional claims: UB-04 / 837I, billed per National Uniform Billing Guidelines.
Report ICD-10-CM and PCS codes to the highest level of specificity using the current edition.

Documentation Required

Unlisted CPT/HCPCS Coding Instructions

When no specific CPT or HCPCS code accurately describes the service, providers must report the procedure using the appropriate unlisted CPT or HCPCS code and comply with the CPT/HCPCS instructions for Unlisted Procedure or Service, including submitting the required special report documentation.

Use the most specific CPT/HCPCS code available that supports medical necessity.
If no specific code exists, report using the appropriate unlisted CPT or HCPCS code and include the Special Report per the current codebook instructions.

Documentation Required

Documentation of Lack of Equally Effective, Conservative, or Less Costly Treatment

Providers must document that no equally effective, more conservative, or less costly treatment is available statewide when claiming medical necessity under the policy's general criteria. Documentation should be included in the medical record to support coverage and claims.

Document why open repair is unacceptable and why endovascular repair is medically necessary for high-risk beneficiaries.
Include imaging, measurements, FDA approval status of the device, and clinical justification that no less invasive or less costly alternative is appropriate.