ModifiedAmeriHealth CaritasPolicy CCP.1469

Percutaneous Arteriovenous Fistula Creation

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This policy governs coverage of percutaneous arteriovenous fistula creation for members who require hemodialysis access. The service may be medically necessary when an FDA-approved device is used and specified clinical, provider, and vascular-anatomy criteria are met; otherwise, it is considered investigational and not medically necessary.

Policy Summary

PayerAmeriHealth Caritas

PolicyPercutaneous Arteriovenous Fistula Creation

Policy CodePolicy CCP.1469

Change TypeModified

Effective DateAugust 1, 2026

Last ReviewAug 1, 2026

Next Review DateDecember 1, 2027

Key ActionSubmit pre-procedure ultrasound vascular mapping showing a vessel diameter of at least 2.0 mm and device-specific artery-vein separation at the fistula creation site.

SourceLink

POLICY UPDATE CHANGES

In 2026, the medical necessity criteria for percutaneous arteriovenous fistula creation were changed to medically necessary based on new Society of Interventional Radiology guideline recommendations.

The policy update history states that coverage was modified in September 2026.

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ModifiedAmeriHealth CaritasPolicy CCP.1469

Percutaneous Arteriovenous Fistula Creation

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Sign up for AmeriHealth Caritas Policy CCP.1469 alerts

Get alerted when Policy CCP.1469 changes without checking for updates manually.

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Policy Summary

PayerAmeriHealth Caritas

PolicyPercutaneous Arteriovenous Fistula Creation

Policy CodePolicy CCP.1469

Change TypeModified

Effective DateAugust 1, 2026

Last ReviewAug 1, 2026

Next Review DateDecember 1, 2027

Key ActionSubmit pre-procedure ultrasound vascular mapping showing a vessel diameter of at least 2.0 mm and device-specific artery-vein separation at the fistula creation site.

SourceLink

POLICY UPDATE CHANGES

In 2026, the medical necessity criteria for percutaneous arteriovenous fistula creation were changed to medically necessary based on new Society of Interventional Radiology guideline recommendations.

The policy update history states that coverage was modified in September 2026.

FDA-approved devices

≥ 2.0 mmMinimum vessel diameter

< 2.0 / < 1.5 mmWavelinQ / Ellipsys separation

77%Fistula maturation rate

9%Overall complication rate

Medical Necessity and Coverage Criteria

Percutaneous arteriovenous fistula creation

Covered when all of the following criteria are met.

Covered percutaneous arteriovenous fistula creation

FDA-approved device: Use one of the following devices: Ellipsys Vascular Access System or WavelinQ Plus EndoAVF System.
Medical necessity criteria
- Procedure-specific training: The procedure is performed by a physician who has completed procedure-specific training.
- End stage renal disease: The member is diagnosed with end stage renal disease.
- No distal surgical fistula option: The member is not a candidate for a distal surgical arteriovenous fistula.
- Adult member: The member is at least 18 years of age.≥ 18 years
- Suitable vascular anatomy: Pre-procedure ultrasound vascular mapping confirms suitable vascular anatomy, including both a minimum vessel diameter of at least 2.0 mm and artery-vein separation at the fistula creation site of less than 2.0 mm for WavelinQ or less than 1.5 mm for Ellipsys.Minimum vessel diameter ≥ 2.0 mm; separation < 2.0 mm for WavelinQ or < 1.5 mm for Ellipsys
  Both mapping criteria must be met.

Coverage is not medically necessary when documented or suspected central venous stenosis is present, including ipsilateral upper-extremity arterial stenosis reflected by a systolic blood pressure difference greater than 20 mm/Hg between arms.

Coverage is not medically necessary when the member has undergone prior vascular surgery at or proximal to the arteriovenous fistula target site.

Coverage is not medically necessary when the member has a diagnosed hypercoagulable state.

Coverage is not medically necessary when the member has had a prior axillary dissection or mastectomy on the ipsilateral side of the proposed arteriovenous fistula site.

Coverage is not medically necessary when there is evidence of vascular disease at the ipsilateral radial artery or adjacent vein site.

Coverage is not medically necessary when the member has a history of steal syndrome from previous hemodialysis vascular access that required intervention or abandonment.

Percutaneous arteriovenous fistula creation is investigational and not medically necessary when the stated medical necessity criteria are not met or when any listed exclusion condition is present.

Related Codes and Clinical Thresholds

Related codesCPT

36836	Percutaneous arteriovenous fistula creation, upper extremity, single access of both the peripheral artery and peripheral vein, including fistula maturation procedures (e.g., transluminal balloon angioplasty, coil embolization) when performed, including all vascular access, imaging guidance and radiologic supervision and interpretation [using thermal energy and ultrasound guidance].
37799	Unlisted procedure, vascular surgery.

Minimum vessel diameter

Minimum vessel diameter≥ 2.0 mm

Required documentationPre-procedure ultrasound vascular mapping

Mapping requirementSuitable vascular anatomy must meet both mapping criteria

WavelinQ artery-vein separation

Maximum separation< 2.0 mm at the fistula creation site

Applicable deviceWavelinQ

Measurement contextSeparation between the artery and vein

Documentation and Denial Risks

Documentation Required

Eligibility and Provider Documentation

Before requesting coverage, document that the procedure uses an FDA-approved device and is performed by a physician who has completed procedure-specific training. Confirm and document that the member has end stage renal disease, is at least 18 years of age, and is not a candidate for a distal surgical arteriovenous fistula.

FDA-approved devices: Ellipsys Vascular Access System or WavelinQ Plus EndoAVF System
Procedure-specific physician training
Member diagnosis of end stage renal disease and age ≥ 18 years
Member is not a candidate for a distal surgical arteriovenous fistula

Documentation Required

Vascular Mapping Documentation

Submit pre-procedure ultrasound vascular mapping documenting suitable anatomy at the proposed fistula creation site. Both the minimum vessel diameter and device-specific artery-vein separation criteria must be met.

Minimum artery and vein diameter: ≥ 2.0 mm

Percutaneous Arteriovenous Fistula Creation

Percutaneous arteriovenous fistula creation establishes hemodialysis access through a minimally invasive endovascular approach rather than an open surgical anastomosis. FDA-approved systems create an artery-to-vein connection using suitable upper-extremity vascular anatomy, generally requiring vessel diameters of at least 2.0 mm. The approach may reduce incision-related vascular injury and preserve more proximal sites for future access, although additional procedures may be needed for fistula maturation or function.

Policy Summary

PayerAmeriHealth Caritas

PolicyPercutaneous Arteriovenous Fistula Creation

Policy CodePolicy CCP.1469

Change TypeModified

Effective DateAugust 1, 2026

Last ReviewAug 1, 2026

Next Review DateDecember 1, 2027

Key ActionSubmit pre-procedure ultrasound vascular mapping showing a vessel diameter of at least 2.0 mm and device-specific artery-vein separation at the fistula creation site.

SourceLink

On This Page

Ellipsys artery-vein separation

Maximum separation< 1.5 mm at the fistula creation site

Applicable deviceEllipsys

Measurement contextSeparation between the artery and vein

Ipsilateral systolic blood pressure difference indicating arterial stenosis

Arterial stenosis indicator> 20 mm/Hg systolic blood pressure difference between arms

MeasurementCompare systolic blood pressure between arms

Clinical contextIpsilateral upper-extremity arterial stenosis

Artery-vein separation: < 2.0 mm for WavelinQ or < 1.5 mm for Ellipsys

Documentation Required

Vascular History and Risk-Factor Documentation

Document the member’s relevant vascular history and current central venous findings before the procedure. Include prior or current thoracic central venous devices and all prior arteriovenous access or other vascular surgeries that could cause venous obstruction.

Pacemakers or thoracic central venous catheters
Prior arteriovenous access surgeries
Other vascular surgeries relevant to the proposed access
Thoracic central vein patency or evidence of central venous obstruction

Denial Risk

Central or Ipsilateral Arterial Stenosis

Coverage may be denied when documented or suspected central venous stenosis or ipsilateral upper-extremity arterial stenosis is present. Evaluate and document the relevant vascular findings, including a systolic blood pressure difference between arms greater than 20 mmHg.

Documented or suspected central venous stenosis
Ipsilateral upper-extremity arterial stenosis
Inter-arm systolic blood pressure difference > 20 mmHg

Denial Risk

Prior Vascular Surgery

Coverage may be denied when the member has prior vascular surgery at or proximal (central) to the proposed arteriovenous fistula target site.

Review and document prior vascular surgery relative to the proposed fistula target site

Denial Risk

Hypercoagulable State

Coverage may be denied when the member has a diagnosed hypercoagulable state.

Document the presence or absence of a diagnosed hypercoagulable state

Denial Risk

Ipsilateral Vascular or Access-Related Risk Factors

Coverage may be denied when specified ipsilateral vascular or access-related risk factors are present at the proposed fistula site.

Prior ipsilateral axillary dissection or mastectomy
Evidence of vascular disease at the radial artery or adjacent vein site
History of steal syndrome from previous hemodialysis vascular access that required intervention or abandonment

Denial Risk

Failure to Meet Core Eligibility Criteria

Coverage may be denied when any core eligibility or medical-necessity criterion is not satisfied. Ensure the submitted record supports the required FDA-approved device, trained physician, member eligibility, surgical-access candidacy assessment, and other applicable criteria before performing or billing the procedure.

Failure to satisfy any required eligibility or medical-necessity criterion
Insufficient documentation supporting the device, provider, member, or procedure-specific requirements