CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Extracranial–Intracranial (EC–IC) Arterial Anastomosis Coverage Criteria

This policy governs coverage criteria for surgical anastomosis between extracranial and intracranial arteries (EC–IC bypass) and applies to BlueCHiP for Medicare and Blue Cross Blue Shield - Rhode Island commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyExtracranial–Intracranial (EC–IC) Arterial Anastomosis Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date12/14/2014

Next Review DateN/A

Key ActionObtain prior authorization via the payer's online tool for BlueCHiP for Medicare (recommended for Commercial).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1procedure code referenced in policy

12/14/2014policy effective date

Not coveredcoverage stance for atherosclerosis

RequiredBlueCHiP for Medicare prior auth

Coverage Criteria for EC–IC Anastomosis

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Indication-based coverage

Coverage for EC–IC anastomosis by indication:

Covered indications: Anastomosis of the extracranial-intracranial arteries is covered for all conditions other than atherosclerosis.

Covered when the indication is not atherosclerosis.

Not covered for atherosclerosis: For treatment of atherosclerosis, EC–IC anastomosis is considered not covered for BlueCHiP for Medicare and not medically necessary for Commercial products because current medical research does not support its safety and efficacy.

Based on EC/IC Bypass Study findings and payer assessment.

Anastomosis of the extracranial–intracranial arteries (EC–IC anastomosis) for the indication of atherosclerosis is not covered for BlueCHiP for Medicare. This determination reflects the payer's assessment that current medical research does not support the safety and efficacy of EC–IC bypass when used to treat intracranial atherosclerotic disease.

For Blue Cross Blue Shield - Rhode Island Commercial products, the use of EC–IC anastomosis to treat atherosclerosis is considered not medically necessary. Claims submitted for this indication may be denied because available evidence does not demonstrate benefit for this patient population.

Provider Actions, Prior Authorization, and Denial Risk

Prior Authorization

Prior Authorization Required

Prior authorization is required for BlueCHiP for Medicare and is recommended for Commercial products for procedures related to atherosclerosis. Participating providers should obtain prior authorization using the payer's online tool for prior authorization and benefit verification.

Applies to anastomosis of the extracranial-intracranial arteries when related to atherosclerosis
Use payer online prior authorization tool for submission and benefit verification

Denial Risk

Denial Risk — Atherosclerosis Indication

Anastomosis of the extracranial–intracranial arteries for the indication of atherosclerosis is not covered for BlueCHiP for Medicare and is considered not medically necessary for Commercial products.

Do not submit claims expecting coverage for atherosclerosis indication
Document alternative, evidence-based treatment rationale if pursued as non-covered care

Prior Authorization

Prior Authorization and Benefit Verification — Recommendation and Process

Verify member benefits and prior authorization requirements before scheduling. Even when prior authorization is recommended (Commercial), obtaining authorization can reduce denial risk. Use the payer's online tools/process to check eligibility and submit authorization requests; confirm submission receipt and retain authorization reference numbers in the medical record.

Check eligibility and benefits via the payer online portal
Retain authorization/reference number and include in claim submission
If service is for atherosclerosis indication, expect denial/not medically necessary determination

Background

Intracranial atherosclerotic disease refers to narrowing or obstruction of arteries within the skull that supply the brain and can lead to transient ischemic attack or ischemic stroke. Typical management focuses on medical therapy such as anticoagulant or antiplatelet treatment and control of vascular risk factors. Surgical EC–IC bypass has been studied in this context but, based on clinical trial evidence and the payer's assessment, has not demonstrated sufficient safety and efficacy to support its use for atherosclerotic disease.

Definitions

EC–IC anastomosis — definition and procedural description

TermEC–IC anastomosis (extracranial–intracranial bypass)

DefinitionSurgical craniotomy with dissection and anastomosis of extracranial and intracranial arteries to create a bypass around occlusive disease.

Procedural descriptionThe physician performs a craniotomy in the affected area, locates the extracranial and intracranial arteries to be anastomosed, dissects them from surrounding tissue, and creates an arterial-to-arterial anastomosis to restore or augment cerebral blood flow.

Typical indicationsUsed to bypass intracranial arterial occlusive disease or other cerebrovascular conditions when revascularization is indicated (coverage varies by indication).

Evidence noteThe EC/IC Bypass Study (1985) failed to demonstrate efficacy of EC–IC bypass in preventing ischemic stroke for atherosclerotic disease.