Extracranial Carotid Angioplasty/Stenting
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Defines coverage criteria, limitations, and supporting rationale for carotid artery angioplasty with stenting and transcarotid artery revascularization for extracranial carotid stenosis for members of Blue Cross and Blue Shield of Louisiana.
Added 'spinal immobility, or tracheostomy' to the first coverage criteria bullet as examples of anatomic contraindications to carotid endarterectomy.
Removed ICD-9 diagnosis and procedure code sections and added ICD-10 diagnosis code section; codes 37238 and 37239 were removed from the policy.
Coverage Criteria for Extracranial Carotid Angioplasty/Stenting
Symptomatic high-surgical-risk coverage
Covered when ALL of the following are met
Any one listed factor suffices
Asymptomatic coverage
Covered when ALL of the following are met
Coverage criteria and evidentiary conclusions
Coverage stance summarized from evidence and supplemental information
Based on limited data and clinical input
Role of TCAR remains inadequately established by RCTs
Consider revascularization selectively
Coverage conditions and program requirements
Covered when ALL of the following are met (CMS-based and institutional requirements):
From CMS national coverage summary
Documented neurologic assessment required
Imaging sequence requirement
Required prior to furnishing CAS
Institutional requirements for program operation
Historical coverage context
Historical coverage context noted by committee approvals
Extracted from policy history narrative; not a full criteria set
Coverage when anatomical contraindication present
Covered when specified stenosis thresholds are met and anatomic contraindication to carotid endarterectomy is present
Examples of anatomic contraindications were expanded in policy history
Coverage when stenosis thresholds AND contraindication/high surgical risk present
Coverage referenced when specific stenosis thresholds and contraindications to endarterectomy are present
Derived from multiple committee approval notes in policy history
Coverage criteria referenced in policy history
Policy history describes coverage for extracranial carotid angioplasty/stenting under specific anatomic and clinical conditions
Added to first coverage criteria bullet per history
Second coverage criterion for asymptomatic >80% was removed per history
Policy history documents revision for high surgical risk wording
Indications for carotid angioplasty and stenting
Covered when criteria referenced in policy history are met (as described):
Referenced throughout policy history
Added/clarified in multiple policy history entries
Coverage when endarterectomy contraindicated or high surgical risk
Policy history indicates procedures are considered under specified anatomic and clinical circumstances
Anatomic contraindications include prior radiotherapy or neck surgery; surgically inaccessible lesions; spinal immobility; tracheostomy
Coverage when endarterectomy contraindicated or patient high surgical risk
Coverage considerations described in policy history
Wording was added to the first coverage criteria bullet per multiple policy history entries
Investigational / not covered when endarterectomy is suitable
Investigational indications
Stated in policy history
Coverage criteria and limitations (policy history)
Policy history indicates covered scenarios and investigational additions/changes
Present throughout policy history
Added to first coverage criteria bullet per history
Stated in policy history
Coverage-related historical criteria
Historical and criteria notes in the provided chunks reference coverage conditions for carotid angioplasty/stenting
Also notes that patients suitable candidates for carotid endarterectomy were added to investigational indications
Referenced covered indications
Coverage language referenced in policy history applies to the following groups
Summary of coverage-related wording changes recorded in policy history; full criteria text not present in these chunks
Coverage when endarterectomy contraindicated or patient high surgical risk
Covered when ALL of the following are met (as reflected in policy history notes):
Explicitly referenced multiple times in policy history
Added to first coverage bullet per history
The policy lists specific situations considered not medically necessary. Among these, complete occlusion (100% stenosis) and carotid angioplasty without associated stenting and embolic protection (except rare cases where stenting was intended but prevented by anatomy) are explicitly included as NMN scenarios. These items should be confirmed against clinical documentation when evaluating claims or prior authorization requests.
The policy states that carotid artery stenting (CAS) is considered investigational for all indications except recently symptomatic patients when carotid endarterectomy (CEA) cannot be performed for anatomic reasons. For recently symptomatic patients who cannot undergo CEA due to anatomic contraindications, CAS may be considered medically necessary; otherwise CAS is not supported for average‑risk patients because randomized trials show higher early adverse events with CAS and similar long‑term outcomes versus CEA.
The American Stroke Association guidance cited in the policy indicates that carotid revascularization is not recommended for patients with severe disability from cerebral infarction that precludes preservation of useful function. This ASA statement informs exclusion of revascularization in patients with prohibitive baseline functional status.
The policy references the USPSTF recommendation that screening for asymptomatic carotid artery stenosis in the general adult population is not recommended (Grade D). This recommendation supports limiting screening-driven interventions and aligns with the policy’s emphasis on documented symptomatic status, high‑grade stenosis, or specific contraindications before considering revascularization.
Coding and Code Updates
| PMA and 510(k) device listings | Multiple FDA PMA and 510(k) identifiers listed for carotid stents and embolic protection devices (examples: P030047, P040012, P050019, P060001, P070012, P140026, P180010, P240009, K042218, K062531, K083300, K143072, K153485, K230402, etc.) |
| not specified | CMS national coverage summary references CAS/PTA with FDA-approved carotid stent and embolic protection device; exact CPT/HCPCS codes not listed in this excerpt |
| ICD-10 | Diagnosis code section added to policy |
| ICD-10 | ICD-10 diagnosis code section was added to the policy |
| ICD-10 | Diagnosis code section added (ICD-10); ICD-9 removed |
| ICD-9 | ICD-9 procedure/diagnosis code set removed per coding updates |
| ICD-10 | ICD-10 diagnosis code section added per coding updates |
| ICD-10 | ICD-10 diagnosis code section added |
| ICD-9 | ICD-9 diagnosis and procedure code sections removed |
| ICD-9 | ICD-9 procedure/diagnosis codes removed from policy |
| ICD-10 | ICD-10 diagnosis code section added to policy |
| ICD-9 (unspecified) | ICD-9 diagnosis codes removed per 01/01/2017 coding update |
| ICD-9 | Removal of ICD-9 diagnosis codes (general reference; specific codes not listed in these chunks) |
| No codes listed |
Prior Authorization, Documentation, and Billing Actions
Prior authorization required to confirm coverage criteria
Prior authorization is required to confirm the procedure meets all coverage criteria, including that the request is for carotid artery angioplasty with placement of an FDA‑approved carotid stent and an FDA‑approved or cleared embolic protection device, documented stenosis severity, symptom timing/status, and demonstration of high surgical risk or, for asymptomatic disease, intensive medical therapy/shared decision‑making as applicable.
- Request must be for CAS with an FDA‑approved carotid stent and FDA‑approved/cleared embolic protection device ([[chunk 3]]).
- Documentation must show stenosis severity and symptom timing/status per coverage thresholds (symptomatic 50–99% or asymptomatic 70–99%) ([[chunk 3]], [[chunk 5]]).
- Asymptomatic coverage requires documented intensive medical therapy or contraindication and shared decision‑making ([[chunk 5]]).
Prior authorization for CAS asserted when CEA not possible (recently symptomatic)
When CAS is asserted as medically necessary because CEA cannot be performed for anatomic reasons in recently symptomatic patients, prior authorization is implied but the request must include documentation that the patient is recently symptomatic and not a candidate for CEA due to anatomic contraindication.
- Policy notes CAS may be considered medically necessary for recently symptomatic patients when CEA cannot be performed for anatomic reasons; include documentation of inability to perform CEA ([[chunk 21]]).
- Coverage criteria for symptomatic patients (including timing and stenosis thresholds) still apply ([[chunk 3]]).
Prior authorization must document indication and program compliance
Prior authorization submissions must demonstrate the patient meets CMS‑consistent coverage conditions (symptomatic stenosis ≥50% or asymptomatic ≥70%) and that required pre/post procedure assessments and facility program standards are met.
- CMS criteria: symptomatic ≥50% or asymptomatic ≥70% ([[chunk 38]]).
- Pre/post neurologic assessment, imaging confirmation, formal shared decision‑making, and facility program standards are required and should be documented ([[chunk 39]], [[chunk 40]]).
Prior authorization (check full policy for PA process)
Policy history documents multiple coverage eligibility revisions and coding changes, but the excerpt does not restate an explicit step‑by‑step prior authorization process; providers should consult the full policy and payer authorization portal for procedural PA instructions.
- Policy history shows many committee reviews and coding updates but does not specify the explicit PA workflow in these excerpts ([[chunk 58]], [[chunk 90]]).
Use current procedure codes and document indications for PA/billing
Ensure prior authorization and billing use current, supported procedure codes and include documentation of the clinical indications (e.g., symptomatic >50% or asymptomatic >80% with contraindication/high surgical risk) rather than the removed CPTs.
Use current CPT codes and document criteria for PA
The policy removes CPT codes 37238 and 37239 in multiple history entries; prior authorization and billing must use currently supported CPTs and clearly document how the case meets criteria (stenosis thresholds and contraindication/high surgical risk).
Coding update / prior authorization note (removed CPTs)
Coding updates note removal of CPT codes 37238 and 37239 from the policy; the provided excerpt does not restate explicit prior authorization requirements tied to this change.
- Policy history documents CPT removals but does not detail a changed PA workflow in these chunks ([[chunk 209]], [[chunk 98]]).
Prior authorization implications from coverage revisions
Policy history revisions to coverage criteria—such as expanding examples of anatomic contraindications—could change prior authorization determinations; include documentation of any cited anatomic contraindication in PA submissions.
- History entries added 'spinal immobility, or tracheostomy' to examples of anatomic contraindications in the first coverage bullet ([[chunk 96]]).
- Policy history emphasizes documenting anatomic contraindications when claiming stenting instead of CEA ([[chunk 252]]).
PA: demonstrate stenosis severity and anatomic contraindications
Prior authorization requests should include documentation showing the degree of stenosis and the specific anatomic contraindication or high surgical risk that makes CEA infeasible.
- Policy history and coverage criteria require documented stenosis severity and demonstration of anatomic contraindication or high surgical risk ([[chunk 252]], [[chunk 3]]).
Medical therapy requirement before authorization for asymptomatic disease
For asymptomatic high‑grade stenosis, prior authorization and documentation should show the patient received intensive medical therapy (targets: systolic BP <130 mmHg, LDL <70 mg/dL) or has a contraindication to optimal medical therapy before coverage of revascularization is considered.
- Asymptomatic coverage requires documented intensive medical therapy with BP target <130 mmHg and LDL <70 mg/dL or documented contraindication to optimal medical therapy ([[chunk 5]]).
Document prior medical management before revascularization
Conservative management with intensive medical therapy is the recommended initial approach for many patients with asymptomatic high‑grade stenosis; prior authorization should reflect that revascularization was considered after optimal medical therapy or appropriate exceptions.
- CREST‑2 and editorial guidance recommend initiating intensive medical therapy and delaying revascularization for asymptomatic patients; PA should document this rationale when applicable ([[chunk 19]]).
- Asymptomatic coverage criteria require either intensive medical therapy or documented contraindication ([[chunk 5]]).
Document shared decision‑making prior to authorization
Prior authorization submissions must document that a shared decision‑making discussion occurred covering CEA, CAS/TCAR, and optimal medical therapy and that patient preferences were considered.
- CMS‑aligned requirements and policy text require a formal shared decision‑making interaction discussing CEA, CAS/TCAR, and OMT prior to CAS ([[chunk 39]]).
- Asymptomatic coverage criteria explicitly require documentation of shared decision‑making ([[chunk 5]]).
Required documentation: stenosis percent and symptom timing
Document the percent stenosis, symptomatic history with timing (including ipsilateral TIA, monocular blindness, or nondisabling stroke), and modified Rankin Scale status when submitting for prior authorization.
- Coverage requires documented severe stenosis percent and symptom timing/type (e.g., ipsilateral TIA or monocular blindness within 180 days or nondisabling stroke with mRS <3) ([[chunk 3]]).
- Required documentation list emphasizes percent stenosis, symptom history/timing, and mRS score ([[chunk 115]]).
Documentation: symptomatic status and imaging‑confirmed stenosis
Include the patient's symptomatic status and the degree of stenosis as measured by duplex ultrasound, CTA/MRA, or catheter angiography in the prior authorization package.
- Documentation should include symptomatic status and degree of stenosis by appropriate imaging modality (≥70% symptomatic severe stenosis or thresholds per policy) ([[chunk 116]]).
- Policy lists duplex ultrasound as first‑line and CTA/MRA or catheter angiography for confirmation when indicated ([[chunk 39]]).
Neurologic assessment and imaging documentation required
Prior authorization and documentation must include neurologic assessment by a neurologist or an NIHSS‑certified professional before and after CAS, and duplex ultrasound results as part of the imaging confirmation.
- Policy requires neurologic assessment by a neurologist or NIHSS‑certified professional before and after CAS ([[chunk 39]]).
- Duplex ultrasound is specified as first‑line evaluation and must be included in documentation ([[chunk 39]]).
Use ICD‑10 diagnosis coding for PA and claims
Use appropriate ICD‑10 diagnosis codes when submitting claims or prior authorization requests; the policy added an ICD‑10 diagnosis code section and removed ICD‑9 codes.
- Policy history documents addition of an ICD‑10 diagnosis code section and removal of ICD‑9 procedure/diagnosis sections—use ICD‑10 for submissions ([[chunk 69]], [[chunk 90]]).
Support anatomic contraindication with documentation
When asserting anatomic contraindication to CEA, include supporting documentation such as prior neck radiotherapy or surgery, surgically inaccessible lesions, spinal immobility, or tracheostomy.
- Policy history expanded examples of anatomic contraindications to include prior radiotherapy/neck surgery, surgically inaccessible lesions, spinal immobility, or tracheostomy and advises documenting these conditions ([[chunk 96]], [[chunk 252]]).
Clinical justification: document stenosis severity and contraindication/high risk
Provide clinical justification for stenting by documenting stenosis severity (symptomatic >50% or asymptomatic preocclusive >80%) and either an anatomic contraindication to CEA or that the patient is high surgical risk due to medical comorbidity.
- Policy history and coverage criteria require documentation of stenosis thresholds and presence of anatomic contraindication or high surgical risk when claiming stenting ([[chunk 108]], [[chunk 3]]).
Denial triggers: requests not meeting coverage criteria
Requests that do not meet coverage criteria—such as procedures for patients suitable for CEA, complete occlusion (100% stenosis), angioplasty without stent/embolic protection, lack of required imaging/embolic protection, or lesions not safely reachable endovascularly—may be denied.
- Policy lists not medically necessary indications including patients suitable for CEA, complete occlusion, angioplasty without stent/EPD, asymptomatic stenosis not meeting criteria, and lesions not safely reachable endovascularly ([[chunk 6]]).
- Coverage criteria require use of an FDA‑approved stent with embolic protection and imaging‑confirmed stenosis thresholds ([[chunk 3]]).
Denial risk: CAS not supported for average‑risk candidates for CEA
CAS requests for average‑risk patients who are suitable candidates for CEA may be denied because randomized trial evidence shows higher early adverse events with CAS and no net health benefit compared with CEA for average‑risk patients.
- Summary of evidence states CAS is not supported for average‑risk patients suitable for CEA due to higher early adverse events and similar long‑term outcomes ([[chunk 18]]).
- Policy lists individuals suitable for CEA among not medically necessary indications for CAS ([[chunk 6]]).
Background and Rationale
Carotid artery stenting (CAS) and transcarotid artery revascularization (TCAR) are described as less‑invasive alternatives to carotid endarterectomy (CEA). CAS is typically performed via transfemoral or transcervical approaches using embolic protection devices, while TCAR employs a direct cervical approach with dynamic flow reversal. Evidence for CAS includes randomized controlled trials comparing CAS and CEA; evidence for TCAR is limited to nonrandomized and observational studies and systematic reviews. These distinctions support the policy’s more restrictive coverage stance for CAS/TCAR compared with CEA.
Coverage decisions in this policy are informed by guideline documents and systematic reviews cited in the references (for example, ROADSTER trial publications and the 2011 ASA/ACC/AHA guideline). While the excerpted references inform clinical context and recommendations, the policy text applies specific coverage criteria and investigational designations rather than listing every guideline‑based exclusion explicitly.
The policy history documents multiple revisions over time but the provided excerpt does not present a separate, comprehensive list labeled 'not medically necessary.' Instead, the NMN examples are embedded within the 'When Services Are Considered Not Medically Necessary' and policy‑history text; explicit NMN wording beyond those embedded examples is not shown in this excerpt.
Definitions and Thresholds
Policy Revision History and Material Changes
Medical Policy Committee reviewed and revised coverage language; coding updates and criteria wording edits (including plans to remove CPT codes 37238/37239) were recorded.
Implementation activities following Medical Policy Committee decisions; coding and policy language changes documented.
Committee approved implementation of prior coding updates and policy revisions, including removal of ICD-9 sections and addition of ICD-10 diagnosis section.
ICD-9 diagnosis codes removed from policy and ICD-10 diagnosis code section added effective 01/01/2017.
Earlier committee approval recorded in policy history as part of recurring reviews of coverage criteria and coding.
Policy history entry notes updates to procedure coding and removal of procedure codes (including 37238/37239) from the policy.
Current policy effective date established as 2026-10-01 with updated coverage criteria and expanded examples of anatomic contraindications.
Material updates in the policy history include expansion of examples of anatomic contraindications to CEA—specifically adding spinal immobility and tracheostomy to the first coverage criteria bullet—and coding updates removing CPT codes 37238 and 37239 and replacing ICD‑9 sections with ICD‑10 diagnosis coding. These changes affect documentation and coding expectations for prior authorization and claims.
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