Percutaneous Revascularization Procedures for Lower Extremity Peripheral Arterial Disease
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Defines medical criteria, prior authorization expectations, and coverage stance for percutaneous revascularization (balloon angioplasty, stent procedures, atherectomy, and lithotripsy) for members of Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage Criteria — Percutaneous Revascularization
Medical necessity for percutaneous revascularization (non-lithotripsy)
Covered when ALL of the following are met for chronic symptomatic PAD:
Applies to balloon angioplasty, stent procedures, and atherectomy; also considered medically necessary for CLTI and acute limb ischemia per policy
Asymptomatic PAD — limited coverage
Covered when:
Limited coverage only in this context
Percutaneous lithotripsy — not covered
Not covered
Codes listed in policy (eg, 37262, 37279, C9764–C9775) are not covered
RCTs and observational studies are limited by lack of comparisons to other percutaneous procedures and small heterogeneous cohorts
Revascularization for symptomatic PAD and CLTI
Covered when clinical evidence supports benefit and guideline-directed therapy has been considered:
Revascularization may improve symptoms and quality of life when medical therapy unsuccessful
Revascularization is standard treatment in CLTI to reduce amputation risk
Surgical revascularization and thrombolysis have different risk profiles; selection based on patient-specific factors
Intravascular lithotripsy (IVL)
IVL for symptomatic PAD:
Coverage stance in this policy treats IVL codes as not covered/not medically necessary despite isolated RCT patency results
Procedures that do not meet the medical criteria set forth in this policy are considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products. This applies to percutaneous revascularization using balloon angioplasty, stent procedures, or atherectomy when the specific clinical criteria for chronic symptomatic peripheral arterial disease (PAD), chronic limb‑threatening ischemia (CLTI), or acute limb ischemia are not satisfied. Providers should ensure the documented clinical indications and required conservative therapies are present before proceeding with these interventions to avoid payment denial or noncoverage determination.
Revascularization procedures that use intravascular lithotripsy (IVL) are explicitly not covered for Medicare Advantage Plans and not medically necessary for Commercial Products in all situations. The policy lists the specific CPT/HCPCS codes for lithotripsy (eg, 37262, 37279, C9764–C9767, C9772–C9775) and states these codes are considered not covered/not medically necessary as the evidence is insufficient to show an improvement in net health outcome.
Coverage and payment decisions are governed by the member’s subscriber agreement, certificate, or employer agreement. Those contractual documents supersede this medical policy. For member‑specific benefits and eligibility, providers must contact the provider call center and verify the member’s coverage prior to scheduling services.
For Commercial Products, percutaneous revascularization performed when the policy’s medical criteria are not met is considered not medically necessary. Similarly, lithotripsy procedures (codes identified in the policy) are considered not covered / not medically necessary in all situations. Providers should obtain and document the required indications and prior conservative management to support medical necessity for percutaneous interventions.
Elective percutaneous revascularization for patients with asymptomatic lower extremity PAD is not supported by the evidence and is therefore not recommended. Randomized and observational data do not demonstrate that early invasive revascularization reduces the development of symptomatic disease, and such procedures may increase the risk of subsequent complications. For asymptomatic disease, the risks of percutaneous revascularization generally outweigh any potential benefit.
If services are determined to be not medically necessary or are medically necessary but are non‑covered benefits, providers may not bill the member for those services unless the member was informed in advance and agreed in writing to accept financial responsibility. Refer to applicable participation and member agreements for contractual obligations related to member billing.
Coding — CPT / HCPCS Guidance
| 0238T | CPT code listed in policy for percutaneous revascularization |
| 0505T | CPT code listed in policy for percutaneous revascularization |
| C7531 | HCPCS code listed in policy for percutaneous revascularization |
| C7534 | HCPCS code listed in policy for percutaneous revascularization |
| C7535 | HCPCS code listed in policy for percutaneous revascularization |
| 37262 | CPT/HCPCS code listed for lithotripsy (not covered) |
| 37279 | CPT/HCPCS code listed for lithotripsy (not covered) |
| C9764 | HCPCS code listed for lithotripsy (not covered) |
| C9765 | HCPCS code listed for lithotripsy (not covered) |
| C9766 | HCPCS code listed for lithotripsy (not covered) |
| C9767 | HCPCS code listed for lithotripsy (not covered) |
| C9772 | HCPCS code listed for lithotripsy (not covered) |
| C9773 | HCPCS code listed for lithotripsy (not covered) |
| C9774 | HCPCS code listed for lithotripsy (not covered) |
| C9775 | HCPCS code listed for lithotripsy (not covered) |
| 0238T | Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel |
| 0505T | Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural road mapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion |
| C7531 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal angioplasty with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation |
| C7534 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with atherectomy, includes angioplasty within the same vessel, when performed with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation |
| C7535 | Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(ies), unilateral, with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, with intravascular ultrasound (initial noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and interpretation |
| 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) (New Code Effective 1/1/2026) |
| 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) (New Code Effective 1/1/2026) |
| C9764 | Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed |
| C9765 | Revascularization ... with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed |
| C9766 | Revascularization ... with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed |
| C9767 | Revascularization ... with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed |
| C9772 | Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed |
| C9773 | Revascularization ... tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed |
| C9774 | Revascularization ... tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed |
| C9775 | Revascularization ... tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed |
Provider Actions — Authorization, Documentation, and Denial Risk
Prior authorization required for Medicare Advantage; recommended for Commercial
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products for the listed percutaneous revascularization CPT/HCPCS codes (0238T, 0505T, C7531, C7534, C7535).
- Applies to percutaneous revascularization using balloon angioplasty, stent procedures, or atherectomy where those codes are used.
Follow payer prior authorization policy for submission
Prior authorization may be required per the payer's separate 'Prior Authorization of Services, Treatments or Procedures' policy; providers should consult that policy before scheduling and follow its submission and documentation instructions.
- Refer to the related Prior Authorization policy for procedural submission requirements.
No specific prior-authorization code list in this section
This section of the medical policy does not provide a specific list of codes tied to an explicit prior authorization process; no additional code-based PA requirements are specified here.
- See the payer's Prior Authorization policy or call the provider call center for member-specific PA requirements.
Require inadequate response to guideline-directed therapy including structured exercise
Before considering percutaneous revascularization for chronic symptomatic PAD, patients should have an inadequate response to guideline-directed management and therapy, including structured exercise programs.
- Structured exercise programs are described as supervised sessions of 30–45 minutes per 60-minute session, at least 3 times per week for a minimum of 12 weeks.
Document attempted structured exercise and medical therapy before revascularization
Structured exercise therapy (supervised exercise program) and guideline-directed medical therapy should be attempted and documented prior to elective revascularization for claudication.
- Document frequency, intensity, time, and duration of supervised exercise (minimum 30–45 minutes/session, ≥3 sessions/week, for ≥12 weeks) and response to medical therapy.
No formal step therapy program specified in this section
The policy text does not state additional step therapy mandates beyond recommending and expecting documentation of structured exercise and guideline-directed medical therapy.
- No formal step-therapy program or step edits are specified in this document.
Required diagnostic documentation: history/physical and ABI testing
Diagnostic confirmation of PAD must include history and physical examination and measurement of the ankle-brachial index (ABI); additional physiologic testing or noninvasive/invasive imaging should be performed as indicated to establish diagnosis and severity.
- Resting ABI is primary diagnostic method; use exercise ABI if resting ABI is normal or borderline in suspected chronic symptomatic PAD.
- Include pulse volume recordings and Doppler waveforms as appropriate.
Clinical documentation must show symptoms, prior therapy, and shared decision-making
Clinical documentation submitted should support severity of symptoms, specify the clinical indication (claudication, CLTI, or acute limb ischemia), and document response to guideline-directed medical therapy including structured exercise (frequency/intensity/duration) and shared decision-making regarding revascularization.
- Document patient-reported functional limitation, results of ABI and any imaging, duration and details of structured exercise therapy (minimum sessions and weeks), and evidence of inadequate response to medical therapy.
Verify member benefits, eligibility, and applicable subscriber/employer documents
Verify member benefits and eligibility with the provider call center and the member's subscriber agreement or employer agreement, which supersede this medical policy for member-specific coverage determinations.
- Contact the provider call center for member-specific benefit or prior authorization information before scheduling.
Procedures not meeting criteria — may be not covered; lithotripsy excluded
Procedures that do not meet the medical criteria in this policy may be considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products; intravascular lithotripsy (listed lithotripsy codes) is considered not covered/not medically necessary in all situations.
Denial risk if treating asymptomatic PAD or without prior noninvasive therapy
Performing invasive revascularization for asymptomatic PAD, or proceeding without documented failure of guideline-directed noninvasive therapy (including structured exercise), may be considered unnecessary and could lead to denial.
- Asymptomatic PAD lacks evidence that early invasive revascularization reduces progression to symptomatic disease; risks may outweigh benefits.
- Ensure documentation of inadequate response to noninvasive therapy before electing revascularization for claudication.
Member financial liability when service is not covered or not medically necessary
If services are determined to be not medically necessary or are non-covered benefits, providers may not bill the member unless the member was informed and provided written agreement in advance; otherwise the provider may be financially liable.
- Notify and obtain the member's written agreement in advance if proceeding with non-covered or not medically necessary services to permit billing the member.
Background — Peripheral Arterial Disease and Interventions
Peripheral arterial disease (PAD) encompasses multiple clinical subsets: asymptomatic PAD (no reported leg symptoms though objective testing may reveal impairment), chronic symptomatic PAD (claudication) (exertional leg symptoms limiting walking that resolve with rest), chronic limb‑threatening ischemia (CLTI) (ischemic rest pain, nonhealing wounds or gangrene persisting >2 weeks), and acute limb ischemia (ALI) (sudden decreased arterial perfusion that threatens limb viability). Treatment options vary by subset; revascularization (surgical or percutaneous) is an accepted option for symptomatic disease and CLTI, whereas invasive procedures for asymptomatic PAD are generally not supported by evidence. Intravascular lithotripsy (IVL) has been evaluated in randomized and nonrandomized studies but the overall evidence is considered insufficient to establish improved net health outcomes.
Definitions — Key Clinical Terms
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