CurrentBlue Cross Blue Shield - MassachusettsPolicy 098

Endovascular Stent Grafts for Abdominal Aortic Aneurysms

Defines medical necessity criteria, coding, and authorization requirements for FDA-approved endovascular endoprostheses used to treat abdominal aortic aneurysms (AAAs) for commercial and Medicare members; includes inpatient preauthorization requirement and lists applicable CPT and ICD-10-PCS codes.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyEndovascular Stent Grafts for Abdominal Aortic Aneurysms

Policy CodePolicy 098

Change TypeClarified (literature update & auth guidance)

Effective DateN/A

Next Review DateN/A

Key ActionPrecertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.

POLICY UPDATE CHANGES

Policy updated with literature review through March 18, 2026; references added.

Outpatient prior authorization information clarified to N/A (service primarily performed inpatient).

Policy title changed to 'Endovascular Stent Grafts for Abdominal Aortic Aneurysms.'

4Medically Necessary Indications Listed

2Investigational Situations Noted

23Procedure Codes Listed

Coverage Summary

Medical-Necessity Criteria

Medically Necessary Criteria

The use of FDA-approved endoprostheses for treatment of AAAs is MEDICALLY NECESSARY when ANY of the following are met:

ANY of the following

An aneurysmal diameter greater than 5.0 cm> 5.0 cm
An aneurysmal diameter of 4 - 5.0 cm that has increased in size by 0.5 cm in the last 6 monthsIncrease of 0.5 cm in last 6 months
An aneurysmal diameter that measures twice the size of the normal infrarenal aortaDiameter twice normal infrarenal aorta
A ruptured abdominal aortic aneurysm

Investigational / Not Medically Necessary

Use of endoprostheses is INVESTIGATIONAL when the medically necessary criteria above are not met, including but not limited to:

ALL of the following

Treatment of smaller aneurysms that do not meet the current recommended threshold for surgery
Treatment of aneurysms that do meet the recommended threshold for surgery in patients who are ineligible for open repair due to physical limitations or other factors

Net health outcome for elective AAA repair: Randomized trials and systematic reviews show early mortality reduction with EVAR but higher long‑term reintervention rates and overall survival comparable to open repair; evidence supports EVAR as an alternative for eligible patients.

EVAR in ruptured AAA: RCTs and meta‑analyses demonstrate comparable short‑ and intermediate‑term survival and reduced perioperative complications with EVAR, supporting an improved net health outcome for ruptured AAAs.

EVAR in patients ineligible for open repair: RCTs did not show superior outcomes versus no surgical intervention; evidence is insufficient to determine an improved net health outcome in this population.

Coding

Covered CPT Codes (must meet medical necessity criteria)CPTCovered

34701	Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft; for other than rupture
34702	Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft; for rupture
34703	Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft; for other than rupture
34704	Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft; for rupture
34705	Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft; for other than rupture
34706	Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft; for rupture
34707	Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft; unilateral; for other than rupture
34708	Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft; unilateral; for rupture
34709	Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies); list separately
34710	Delayed placement of distal or proximal extension prosthesis; initial vessel treated

1–10 of 19

1/2

Relevant ICD-10-PCS Procedure CodesICD-10Covered

04V03DZ	Restriction of Abdominal Aorta with Intraluminal Device, Percutaneous Approach
04U04JZ	Supplement Abdominal Aorta with Synthetic Substitute, Percutaneous Endoscopic Approach
04U03JZ	Supplement Abdominal Aorta with Synthetic Substitute, Percutaneous Approach
04V04DZ	Restriction of Abdominal Aorta with Intraluminal Device, Percutaneous Endoscopic Approach

Provider Actions

Prior Authorization

Precertification required for inpatient procedures

Precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.

Applies to all products if procedure performed inpatient

Documentation Required

Medical necessity documentation

Medical record must document aneurysm measurements and growth to demonstrate the applicable medical necessity criterion (e.g., diameter, growth of 0.5 cm in 6 months, comparison to normal infrarenal aorta, or rupture).

Aneurysm diameter (e.g., > 5.0 cm)
Documented growth (increase of 0.5 cm in the last 6 months for 4–5.0 cm aneurysms)
Comparison showing diameter twice the size of the normal infrarenal aorta
Evidence of rupture

Billing Rule

Report services with current codes and modifiers

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

Report services with current procedure, revenue, and diagnosis codes and include applicable modifiers

Background & Definitions

Endovascular stent grafts (EVAR) are catheter‑delivered prosthetic grafts deployed to exclude an AAA from circulation and restore normal flow; they are a less invasive alternative to open surgical repair but raise concerns about long‑term durability and anchor failure.

Devices include tube (straight), bifurcated, fenestrated, and branched grafts, plus extension prostheses to seal or reach visceral/iliac arteries. Key clinical considerations include durability, risk of aneurysm expansion from endoleaks (perivascular leaks from attachment site failure, collateral flow, or graft fabric perforation), and need for long‑term surveillance and possible reintervention.

Term	Definition
Endoprosthesis / Endovascular stent graft (EVAR)	A catheter-delivered prosthetic graft deployed across an aneurysm to exclude it from circulation and restore normal flow.

Evidence Summary

Key evidence statements

Net health outcome for elective AAA repairRCTs and systematic reviews: early mortality reduction with EVAR but higher long-term reintervention rates and comparable overall survival vs open repair; sufficient evidence to support EVAR as an alternative for eligible patients.

EVAR in ruptured AAARCTs and meta-analyses: comparable short- and intermediate-term survival with reduced perioperative complications; evidence supports improved net health outcome.

EVAR in patients ineligible for open repairRCTs did not show superior outcomes; evidence insufficient to determine improved net health outcome for this population.

Revision History

7/2016revised

Policy title changed to 'Endovascular Stent Grafts for Abdominal Aortic Aneurysms.'; Policy statements unchanged.

9/2019clarified