Blue Cross MA percutaneous revascularization Coverage Update

Coverage Criteria

Chronic Symptomatic Peripheral Arterial Disease - Medically Necessary

Percutaneous revascularization (balloon angioplasty, stent, atherectomy) may be considered MEDICALLY NECESSARY when:

Chronic symptomatic PAD—claudication: Functionally limiting claudication (see Policy Guidelines)

Conservative therapy failed: Inadequate response to guideline-directed management and therapy (GDMT), including structured exercise

Structured exercise program minimums described in policy

Benefit outweighs risk: Potential benefits of revascularization on quality of life, walking performance, and functional status outweigh the risks and durability concerns and possible need for repeated procedures

See Practice Guidelines

Chronic Limb-Threatening and Acute Limb Ischemia

Percutaneous revascularization is considered MEDICALLY NECESSARY for:

Chronic limb‑threatening ischemia (CLTI): Treatment of chronic limb‑threatening ischemia to minimize tissue loss and preserve limb/ambulatory functionsymptoms > 2 weeks for CLTI context

Revascularization (endovascular or surgical) is standard treatment

Acute limb ischemia (ALI): Treatment of acute limb ischemia to restore limb perfusion and attempt limb salvage

Evidence supports surgical and endovascular approaches

Asymptomatic Peripheral Arterial Disease

Asymptomatic PAD:

Asymptomatic PAD enabling other procedures: Percutaneous revascularization may be considered medically necessary if needed for the safety, feasibility, or effectiveness of other invasive, clinically necessary, life‑saving procedures (eg, transfemoral aortic valve replacement, mechanical circulatory support, endovascular aortic aneurysm repair)

Other asymptomatic PAD: Percutaneous revascularization for asymptomatic PAD is considered investigational/not supported in all other situations because early invasive revascularization has not been shown to reduce progression to symptomatic disease and may increase risk of complications

Lithotripsy

Lithotripsy: Use of intravascular lithotripsy for lower‑extremity peripheral arterial disease

Considered investigational in all situations

Investigational / Not Medically Necessary

Policy stance for intravascular lithotripsy

Investigational codes: CPT codes 37262 and 37279 (intravascular lithotripsy, iliac and femoral/popliteal territories) are considered investigational for Commercial Members and specified Medicare products

No clinical coverage criteria provided for these codes; investigational status may affect coverage/prior authorization

Medically Necessary Indications

Covered when ALL of the following are met

General coverage context: Revascularization (endovascular or surgical) is considered standard treatment for CLTI and can improve symptoms and quality of life for chronic symptomatic PAD refractory to guideline‑directed medical treatment including structured exercise

Supports coverage for CLTI and selected symptomatic PAD

Not Medically Necessary / Investigational

Not covered / investigational when

Asymptomatic PAD (general): Percutaneous revascularization for asymptomatic lower extremity PAD is not supported in general because early invasive revascularization has not been shown to reduce progression to symptomatic disease and is associated with increased risk of subsequent complications

Except when required to enable other invasive, clinically necessary, life‑saving procedures

Lithotripsy (general): Percutaneous revascularization using intravascular lithotripsy is considered investigational and not medically necessary in all situations

CPT codes 37262 and 37279 listed as investigational

Lithotripsy (Investigational/Insufficient Evidence)

Lithotripsy — evidence summary and stance

Intravascular lithotripsy evidence: Evidence includes one RCT showing improved 1‑year primary patency for lithotripsy versus control and nonrandomized studies, but limitations (lack of comparisons to other percutaneous procedures, small and heterogeneous studies) leave net health benefit unproven

Investigational/insufficient evidence for general adoption

The policy designates use of intravascular lithotripsy (IVL) for lower extremity peripheral arterial disease as INVESTIGATIONAL in all situations. This investigational stance applies to percutaneous revascularization procedures that employ lithotripsy rather than to other endovascular techniques such as angioplasty, stent placement, or atherectomy, which have separate medical necessity criteria. The policy does allow that asymptomatic PAD may be considered medically necessary only when revascularization is required to enable the safety, feasibility, or effectiveness of another invasive, clinically necessary, life‑saving procedure; in all other asymptomatic PAD scenarios, invasive procedures (including lithotripsy) remain investigational or not supported.

The policy provides an extensive list of ICD‑10 diagnosis codes related to peripheral atherosclerosis and related conditions that are applicable when submitting claims for percutaneous revascularization. These diagnosis codes should be used to support medical necessity when the patient meets the policy’s clinical criteria; the codes themselves do not replace the requirement that medical necessity criteria be documented and met.

The document identifies CPT codes 37262 and 37279 as the intravascular lithotripsy procedure codes and states that these codes are considered investigational for Commercial Members and specified Medicare products. As such, use of these CPT codes is flagged in the policy as investigational and may affect coverage determinations for the listed member types.

The evidence summarized in the policy indicates that early invasive revascularization for individuals with asymptomatic PAD has not been shown to reduce progression to symptomatic disease. Available studies, including randomized and observational data, do not demonstrate a net health benefit from routine early invasive procedures and indicate an increased risk of subsequent complications and need for additional procedures. Therefore, early invasive revascularization for asymptomatic PAD is not supported by the evidence.

Several sections of the document are reference material (clinical trials, guidelines, and other citations) intended to support the clinical rationale. Those reference‑only excerpts do not themselves state explicit coverage exclusions; coverage positions and exclusion language are specified elsewhere in the policy text.

Consistent with the policy statements, percutaneous revascularization procedures that utilize lithotripsy are considered not medically necessary / investigational. The investigational determination for lithotripsy applies across indications unless otherwise explicitly addressed in separate coverage criteria.

The policy specifically identifies CPT codes 37262 and 37279 as investigational. As investigational codes, these CPT codes are noted as not medically necessary for the listed Commercial and specified Medicare member types in the policy.

For individuals with asymptomatic lower extremity PAD, the policy states that percutaneous revascularization is considered not medically necessary except when the procedure is required to permit the safety, feasibility, or effectiveness of another invasive, clinically necessary, life‑saving procedure (for example, transfemoral aortic valve replacement or endovascular aortic aneurysm repair). In other asymptomatic situations, revascularization is not supported because the risks outweigh proposed benefits.

The document includes reference sections (clinical trials, observational studies, and guidelines) that inform the policy, but those reference excerpts do not contain standalone statements declaring procedures to be 'not medically necessary'; the formal coverage and 'not medically necessary' determinations are articulated in the policy body.

Coding and Procedure Codes

Covered CPT Codes (informational list)CPT

37254	Revascularization, endovascular, iliac territory, transluminal angioplasty; straightforward lesion, initial vessel
37255	Revascularization, endovascular, iliac territory, angioplasty; each additional vessel
37256	Revascularization, endovascular, iliac territory, angioplasty; complex lesion, initial vessel
37257	Revascularization, endovascular, iliac territory, angioplasty; complex lesion, each additional vessel
37258	Revascularization, endovascular, iliac territory, stent placement; straightforward lesion, initial vessel
37259	Revascularization, endovascular, iliac territory, stent placement; each additional vessel
37260	Revascularization, endovascular, iliac territory, stent placement; complex lesion, initial vessel
37261	Revascularization, endovascular, iliac territory, stent placement; complex lesion, each additional vessel
37263	Revascularization, endovascular, femoral and popliteal territory, angioplasty; straightforward lesion, initial vessel
37264	Revascularization, endovascular, femoral and popliteal territory, angioplasty; straightforward lesion, each additional vessel

1–10 of 23

1/3

Covered CPT CodesCPTCovered

37274	Revascularization, endovascular, femoral and popliteal territory, with transluminal atherectomy, complex lesion, initial vessel
37275	Revascularization, endovascular, femoral and popliteal territory, with transluminal atherectomy, each additional vessel
37276	Revascularization, endovascular, femoral and popliteal territory, with transluminal stent placement with transluminal atherectomy, straightforward lesion, initial vessel
37277	Revascularization, endovascular, femoral and popliteal territory, with transluminal stent placement with transluminal atherectomy, each additional vessel
37278	Revascularization, endovascular, femoral and popliteal territory, with transluminal stent placement with transluminal atherectomy, complex lesion, initial vessel
37280	Revascularization, endovascular, tibial and peroneal territory, with transluminal angioplasty, straightforward lesion, initial vessel
37281	Revascularization, endovascular, tibial and peroneal territory, with transluminal angioplasty, straightforward lesion, each additional vessel
37282	Revascularization, endovascular, tibial and peroneal territory, with transluminal angioplasty, complex lesion, initial vessel
37283	Revascularization, endovascular, tibial and peroneal territory, with transluminal angioplasty, complex lesion, each additional vessel
37284	Revascularization, endovascular, tibial and peroneal territory, with transluminal stent placement, straightforward lesion, initial vessel

1–10 of 27

1/3

Covered HCPCS CodesHCPCSCovered

C7531	Revascularization, femoral/popliteal, with transluminal angioplasty with intravascular ultrasound
C7534	Revascularization, femoral/popliteal, with atherectomy and IVUS
C7535	Revascularization, femoral/popliteal, with transluminal stent placement(s) and IVUS
C9764	Lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy
C9765	Lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and stent placement
C9766	Lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and atherectomy
C9767	Lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, stent placement, and atherectomy
C9772	Tibial/peroneal artery(ies), with intravascular lithotripsy
C9773	Tibial/peroneal artery(ies), with intravascular lithotripsy and stent placement
C9774	Tibial/peroneal artery(ies), with intravascular lithotripsy and atherectomy

1–10 of 11

1/2

Covered ICD-10 Diagnosis CodesICD-10

I70.201	Unspecified atherosclerosis of native arteries of extremities, right leg
I70.202	Unspecified atherosclerosis of native arteries of extremities, left leg
I70.203	Unspecified atherosclerosis of native arteries of extremities, bilateral legs
I70.208	Unspecified atherosclerosis of native arteries of extremities, other extremity
I70.209	Unspecified atherosclerosis of native arteries of extremities, unspecified extremity
I70.211	Atherosclerosis of native arteries of extremities with intermittent claudication, right leg
I70.212	Atherosclerosis of native arteries of extremities with intermittent claudication, left leg
I70.213	Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs
I70.218	Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity
I70.219	Atherosclerosis of native arteries of extremities with intermittent claudication, unspecified extremity

1–10 of 41

1/5

Investigational CPT CodesCPTNot Covered

37262	Intravascular lithotripsy(ies), iliac vascular territory, including all imaging guidance and radiological supervision and interpretation necessary to perform the intravascular lithotripsy(ies) within the same artery (List separately in addition to code for primary procedure).
37279	Intravascular lithotripsy(ies), femoral and popliteal vascular territory, including all imaging guidance and radiological supervision and interpretation necessary to perform the intravascular lithotripsy(ies) within the same artery (List separately in addition to code for primary procedure).

Relevant ICD-10 Diagnosis CodesICD-10

I70.345	Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot.
I70.348	Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg.
I70.349	Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site.
I70.35	Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration.
I70.361	Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, right leg.
I70.362	Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, left leg.
I70.363	Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, bilateral legs.
I70.368	Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, other extremity.
I70.369	Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, unspecified extremity.
I70.391	Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg.

1–10 of 172

1/18

Procedures discussedmixed

No codes listed

Lithotripsy evidence referencesmixed

No codes listed

Structured exercise program minimums

Session lengthSupervised sessions 30–45 minutes per 60‑minute session

FrequencyAt least 3 times per week

Program durationMinimum of 12 weeks

Duration for CLTI

CLTI duration thresholdSymptoms present longer than 2 weeks

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

For services described in this policy, precertification/prior authorization is required for inpatient procedures. Outpatient prior authorization rules vary by product; for many Commercial products (Managed Care HMO/POS, PPO, Indemnity) and Medicare PPO Blue, outpatient prior authorization is not required. Providers should verify current prior authorization requirements with the payer before scheduling procedures.

Inpatient: precertification/prior authorization IS REQUIRED for all products when procedure is performed inpatient.
Outpatient: many Commercial and Medicare products = prior authorization NOT required; verify product-specific rules.

Billing Rule

Submit Listed CPT/HCPCS with Diagnosis

Submit the appropriate CPT and HCPCS codes for the performed procedure along with an ICD-10 diagnosis code that documents medical necessity and links to the procedure. Claims that do not include one of the listed ICD-10 diagnosis codes or that lack documentation demonstrating medical necessity may be denied.

Background and Clinical Context

Evaluation of PAD should include a focused history and physical examination, objective vascular testing such as the ankle‑brachial index (ABI), physiologic testing when indicated, and noninvasive or invasive imaging as appropriate. Documentation of functional status and, when used, treadmill or exercise ABI testing to assess walking impairment are important elements to support medical necessity for revascularization procedures.

Definitions

Functional status

DefinitionFunctional status is an individual’s ability to meet basic needs, fulfill usual roles, and maintain health and well-being (activities of daily living)

ComponentsIncludes walking ability, walking performance, and mobility

Assessment relevanceTreadmill exercise ABI testing can objectively assess baseline functional status and response to therapy in chronic symptomatic PAD

Structured Exercise Program

DefinitionA structured exercise program is planned by a qualified health care professional with individualized recommendations for frequency, intensity, time, and type of exercise

SupervisionClassified as supervised exercise therapy or structured community-based programs; supervised sessions have set training time

Revision History & Policy Changes

2026-01coding clarificationLatest

Clarified coding information in the policy.

2025-12annual review

Annual policy review with literature update through September 3, 2025; references added and policy statements unchanged.

Within the policy’s prior authorization and provider instructions, there are reference‑only sections listing literature, guideline, and technical references to support clinical rationale. Those reference excerpts do not list any explicit prior authorization (PA) codes or requirements; the policy separately notes that inpatient procedures require precertification while outpatient PA requirements vary by product.

OpenPayer

Endovascular percutaneous revascularization for lower extremity peripheral arterial disease