CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Extracranial-Intracranial Arteries Anastomosis Coverage Policy

Defines coverage criteria for extracranial-intracranial arterial anastomosis (EC-IC bypass), specifying that the procedure is not medically necessary for atherosclerosis and covered for other indications; prior authorization requirements are noted.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyExtracranial-Intracranial Arteries Anastomosis Coverage Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionPrior authorization is required for BlueCHiP for Medicare for extracranial-intracranial anastomosis; obtain via the online tool for participating providers.

SourceLink

POLICY UPDATE CHANGES

No material changes

1CPT code listed as not medically necessary

All other indicationsCovered indications (qualitative)

Coverage Summary

Defines coverage criteria for extracranial-intracranial arterial anastomosis (EC-IC bypass). The procedure is not medically necessary for atherosclerosis and is covered for other indications. Prior authorization is required for BlueCHiP for Medicare and recommended for Commercial products for atherosclerosis. Key stats: 1 CPT code listed as not medically necessary; All other indications considered covered.

Scope & Quick Facts

SubjectExtracranial-Intracranial (EC-IC) Arterial Anastomosis

Coverage stanceNot medically necessary for atherosclerosis; covered for all other conditions

StatusCURRENT

Key CPT61711 (anastomosis, arterial, extracranial-intracranial)

Prior authorizationRequired for BlueCHiP for Medicare; recommended for Commercial for atherosclerosis

Medical Criteria

Coverage determination based on underlying condition:

Not medically necessary for:
- Atherosclerosis — Anastomosis of the extracranial-intracranial arteries is considered not medically necessary as current medical research does not support its safety and efficacy.
Covered for:
- All other uses/conditions (i.e., indications other than atherosclerosis) — Anastomosis of the extracranial-intracranial arteries is covered.

ref": "b1_0

title": "Medical Criteria

ref":

Not Medically Necessary / Experimental Uses

Anastomosis of the extracranial-intracranial arteries (EC-IC bypass) is considered not medically necessary for atherosclerosis because current medical research does not support its safety and efficacy. The policy cites the randomized EC/IC Bypass Study Group trial (1985), which failed to show benefit of EC-IC bypass in preventing ischemic stroke in patients with atherosclerotic carotid/middle cerebral disease. Per the policy, EC-IC bypass is covered for all conditions other than atherosclerosis, and CPT code 61711 is designated as not medically necessary when used for atherosclerosis.

Quick Access

Quick access - Not medically necessary: Atherosclerosis — Anastomosis of the extracranial-intracranial arteries is considered not medically necessary as current medical research does not support its safety and efficacy.

CPT 61711 considered not medically necessary for atherosclerosis.

Provider Actions

Prior Authorization

Prior authorization required for BlueCHiP for Medicare

Prior authorization is required for BlueCHiP for Medicare for extracranial-intracranial anastomosis; obtain via the online tool for participating providers.

Prior Authorization

Prior authorization recommended for Commercial products

Prior authorization is recommended (but not required) for Commercial products for atherosclerosis and is obtained via the online tool for participating providers.

Denial Risk

Denial risk for atherosclerosis indication

Claims for EC-IC anastomosis for atherosclerosis are considered not medically necessary and are subject to denial.

61711

Background & Evidence

Intracranial atherosclerotic disease is narrowing or obstruction of arteries within the skull caused by atheromatous plaques in the endothelial layer. It can lead to transient ischemic attack (TIA), stroke, or death, and is usually diagnosed in patients presenting with TIA or stroke. Standard treatment is medical therapy — anticoagulant (e.g., warfarin) or antiplatelet (e.g., aspirin) therapy — along with risk factor management.

Historically, the EC/IC Bypass Study Group (1985) conducted an international randomized trial testing whether extracranial–intracranial arterial bypass reduced ischemic stroke risk in patients with atherosclerotic disease of the carotid and middle cerebral arteries. That trial failed to confirm benefit, forming the basis for the policy determination that EC-IC bypass is not effective for atherosclerotic indications.

Evidence	Details
{"text":"Key trial","status":""},{"text":"EC/IC Bypass Study Group (1985) — failed to confirm benefit in preventing cerebral ischemia in patients with atherosclerotic disease of the carotid and middle cerebral arteries","status":""}
{"text":"Regulatory reference","status":""},{"text":"CMS National Coverage Determination for Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery (20.2) referenced","status":""}

Name	Number	Type	Effective Date
{"text":"Extracranial-Intracranial (EC-IC) Arterial Bypass Surgery","status":""},{"text":"20.2","status":""},{"text":"NCD","status":""},{"text":"","status":""}