Miscellaneous Vascular Embolization Procedures
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Defines medical necessity, non-coverage, and prior authorization expectations for a range of vascular embolization procedures for Medicare Advantage and Commercial Products; excludes liver and uterine fibroid embolization and directs providers to related prior authorization policy.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary indications
Procedures considered medically necessary when listed clinical criteria are met
Medically necessary embolization procedures
- Coil embolization in the treatment of arterio-venous malformations (AVMs)/aneurysm and splenic artery aneurysm
- Coil embolization of gastric varices
- Endovascular embolization for an extracranial AVM or fistula
- Geniculate artery embolization for knee hemarthrosis following total knee arthroplasty
Requires failure of conservative therapies (e.g., ice, immobilization, compression, saline lavage, corticosteroid instillation, selective COX-2 inhibitors) and demonstrated synovial hyper-vascularity on angiography
- Splenic artery embolization for hypersplenism secondary to hepatic cirrhosis as an alternative to splenectomy
- Transcatheter arterial embolization for non-variceal upper gastrointestinal bleeding
- Vascular embolization for the treatment of type I or type II endovascular leak
- Pre-operative embolization of skull base meningiomas
- Renal artery embolization/angioinfarction as a pre-operative adjunct to nephrectomy for large, hypervascular renal cell carcinomas
- Selective arterial embolization for the treatment of giant cell tumor
- Tumor embolization or pre-operative tumor embolization to reduce intra-operative bleeding prior to surgical resection in hypervascular tumors or metastases
- TACE or TAE as therapeutic interventions for actively bleeding malignant or nonmalignant lesions
Not covered / Not medically necessary
Procedures considered not covered / not medically necessary due to insufficient evidence
Tumor Embolization - Medically Necessary
Tumor embolization coverage statement
TACE may be indicated for symptomatic functional neuroendocrine liver metastases in patients with adequate hepatic function (bilirubin < 2 mg/dL; absence of ascites; no portal vein occlusion; tumor involvement < 65% of liver) and after failure of systemic therapy for carcinoid syndrome; safety and effectiveness of more than 4 TACE procedures is unknown.
Investigational / Insufficient Evidence Indications
Other embolization indications with evidence statements
Most indications are described as promising in small studies or systematic reviews but overall evidence is insufficient to determine effects on health outcomes; specific nuances and conflicting meta-analyses exist for pre-operative embolization of carotid body tumors.
This policy does not address vascular embolization for the liver or uterine fibroids. Providers should refer to the related "Prior Authorization via Web‑Based Tool for Procedures" and the Medical Necessity policy referenced in the Related Policies section for coverage, prior authorization, and clinical criteria specific to hepatic or uterine fibroid embolization.
Hemorrhoidal artery embolization (superior rectal artery embolization / SRAE) is described in the literature as a promising technique but with inadequate quality and quantity of evidence to determine safety and effectiveness. Guideline guidance and systematic reviews conclude that current evidence is insufficient; therefore, hemorrhoidal embolization should only be used in the context of research (for example, clinical trials or other well‑designed investigational studies) until higher‑quality comparative data are available.
The following embolization procedures have insufficient evidence to determine meaningful effects on health outcomes and are therefore considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products: 1) locoregional embolization for metastatic pancreatic cancer; 2) endovascular embolization for spinal dural arteriovenous fistula; 3) genicular artery embolization for osteoarthritis‑related knee pain; 4) hemorrhoidal embolization using HydroPearl microspheres; 5) HydroPearl microspheres for lower‑extremity AVMs; 6) bariatric arterial embolization for obesity; 7) middle meningeal artery embolization for chronic subdural hematoma; 8) pre‑operative embolization for carotid body tumor resection; 9) pre‑operative inferior mesenteric artery embolization to reduce type II endoleak after EVAR; and 10) prostatic arterial embolization for benign prostatic hyperplasia.
Prostatic arterial embolization (PAE) for benign prostatic hyperplasia is considered experimental / not established. Specialty guidance (American Urological Association) and recent reviews note safety concerns (radiation exposure, post‑embolization syndrome, nontarget embolization, technical feasibility) and limited long‑term comparative data versus standard treatments. As a result, PAE should be performed only in the context of a clinical trial or research setting, and larger randomized comparative studies versus TURP or other standard therapies are needed to determine safety and effectiveness.
Coding and Limits
| 37242 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) [for embolization of the inferior mesenteric artery] |
| 37243 | Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction |
Provider Actions and Prior Authorization
Prior Authorization Required
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products via the web-based tool for participating providers. Providers should use the payer's web-based prior authorization tool to determine if a procedure requires prior authorization and to submit requests.
- Medicare Advantage: prior authorization required
- Commercial Products: prior authorization recommended via web-based tool for participating providers
- Refer to Related Policies: Prior Authorization via Web-Based Tool for Procedures
Benefits Verification
Verify member-specific benefits, eligibility, and prior authorization requirements before scheduling or performing services. Benefits may vary by group/contract; refer to the member’s Evidence of Coverage or Subscriber Agreement for coverage details.
- Contact the provider call center for member-specific benefits and eligibility
- Benefits/coverage determined by Evidence of Coverage or Subscriber Agreement
Member Financial Liability if Non‑Covered
If services are determined to be not medically necessary or are non-covered benefits, the provider may not bill or collect payment from the member unless the member was informed in advance and provided written agreement to accept financial responsibility. Refer to your participation agreement(s) for applicable provisions.
- Do not charge members for services determined not medically necessary or non-covered unless there is a signed advance written agreement
- Review participation agreement(s) for additional billing provisions
Support Clinical Necessity in the Chart
Document the clinical rationale and supporting evidence in the medical record to substantiate medical necessity when billing the listed CPT codes (for example, 37242, 37243) or when requesting prior authorization. Include pertinent imaging, angiography findings (e.g., synovial hyper-vascularity when applicable), failed conservative therapies, and prior treatments.
- Support chart with imaging and procedural findings (eg, angiography)
- Document failure of conservative therapies when required
- Include prior treatments and clinical justification when submitting prior authorization
Conservative Therapy Prerequisite
Some interventions require evidence of failure of conservative therapy before they are considered medically necessary. Ensure documentation of prior conservative management (for example: ice, immobilization, compression, saline lavage, corticosteroid instillation, selective COX‑2 inhibitors) when applicable.
- Document failed conservative therapies when required by the medical criteria (eg, geniculate artery embolization after failed conservative therapies)
- List dates, duration, and response to conservative treatments in the chart
Conservative Therapy Preference
When guideline-based conservative therapies are appropriate, those should be attempted prior to experimental or investigational interventions (for example, Prostatic Arterial Embolization (PAE) for BPH is considered experimental and, when pursued, is preferred in the context of a clinical trial or after standard therapies have failed).
- PAE for BPH: consider only in context of clinical trials or after failure of medical/surgical standard therapies
- Prefer guideline-directed conservative or standard-of-care treatments before experimental interventions
Background
Vascular embolization is a minimally invasive endovascular technique that purposefully occludes blood vessels without open surgery. It is used broadly to stop arterial bleeding, reduce blood flow to tumors (therapeutic or pre‑operative embolization to limit intraoperative bleeding), shrink or treat vascular malformations, and to redirect blood flow for other indications. The policy addresses a range of embolization applications and distinguishes established, medically necessary indications from investigational or not‑covered uses; hepatic and uterine fibroid embolization are excluded from this policy and handled under other related policies.
Definitions
Revision History
Policy became effective on August 1, 2024.
Policy was last reviewed on April 17, 2024.
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