RetiredCapital BluecrossPolicy MP 1.149

ENDOVASCULAR THERAPIES FOR EXTRACRANIAL VERTEBRAL ARTERY DISEASE

This Capital Blue Cross medical policy (MP 1.149) governs coverage determination for endovascular therapy, including percutaneous transluminal angioplasty with or without stent implantation, for management of extracranial vertebral artery disease (segments V1-V3). It states the intervention is considered not medically necessary (not covered) and provides background, evidence summary, coding, product variations, and references.

Policy Summary

PayerCapital Bluecross

PolicyENDOVASCULAR THERAPIES FOR EXTRACRANIAL VERTEBRAL ARTERY DISEASE

Policy CodePolicy MP 1.149

Change TypeRetirement / coding updates / coverage clarification

Effective DateRetired 4/1/2025

Next Review Date01/24/2025 (Retirement Review)

Key ActionConfirm the member's specific health benefit plan terms and obtain prior authorization or contact Capital Blue Cross Provider/Member Services to determine benefit applicability.

POLICY UPDATE CHANGES

Policy retired effective 4/1/2025 (Retirement Review 01/24/2025 noted; cardiac services delegated to TurningPoint).

05/12/2021: Changed statement from investigational to not medically necessary.

11/29/2022: Administrative update adding procedure code C7532 effective 1/1/2023.

Not coveredPolicy Coverage Position

V1-V3Anatomic Scope

VIST, VASTRandomized Trials Cited

Coverage Summary

This policy (MP 1.149) covers endovascular therapy, including percutaneous transluminal angioplasty with or without stent implantation, for extracranial vertebral artery disease (segments V1–V3). The policy states that endovascular angioplasty with or without stenting for extracranial vertebral artery disease is considered not medically necessary / not covered. Policy status: RETIRED (retired effective 4/1/2025), and cardiac services have been delegated to TurningPoint.

Key Facts

Policy Coverage PositionNot medically necessary (endovascular therapy, including angioplasty ± stenting, is considered not medically necessary)

Anatomic SegmentsExtracranial vertebral artery segments V1-V3

Randomized Trials CitedVIST and VAST (2 trials) — did not demonstrate clear benefit vs medical therapy

Policy StatusRETIRED (effective 4/1/2025; Retirement Review 01/24/2025 noted)

Last Review Date2025-01-24

Medical-Necessity / Coverage Decision

Coverage Decision

Policy statement:

Not Medically Necessary: Endovascular therapy, including percutaneous transluminal angioplasty with or without stenting, is considered not medically necessary for the management of extracranial vertebral artery disease.

Policy retired effective 4/1/2025; coding and rationale history documented.

Anatomic Definition / Scope

Defines extracranial vertebral artery segments:

Anatomic Scope: Extracranial vertebral artery segments V1-V3 (from origin at subclavian artery until vessel crosses the dura mater) are considered under this policy.

V1–V3 defined per policy anatomy section.

Not Covered — Evidence Summary & Rationale

Randomized evidence from the VIST and VAST trials did not demonstrate a clear advantage of vertebral artery stenting over best medical therapy in patients with symptomatic extracranial vertebral artery stenosis.

Noncomparative registry and case-series data report high procedural technical success and generally low periprocedural morbidity and mortality, but long-term follow-up has shown high rates of in-stent restenosis and limited evidence on net long-term benefit. Additionally, the U.S. Food and Drug Administration has not approved devices specifically for treatment of extracranial vertebral artery disease; available stents used are typically approved for carotid or coronary use or are approved for intracranial indications under humanitarian device exemptions.

Extracranial vertebral artery disease (segments V1–V3) may be caused by atherosclerotic stenosis, dissection, aneurysm, or arteriovenous (AV) fistula. Management options include medical therapy (antiplatelet/anticoagulant therapy and vascular risk factor control) and surgical revascularization, with endovascular angioplasty and stenting studied as an alternative but without clear randomized-trial benefit.

Coding

Not Medically Necessary Procedure CodesmixedNot Covered

37246	Transcatheter placement of intravascular stent(s), cervical or intracranial vessels (listed as included in NMN coding)
37247	Transcatheter placement of intravascular stent(s), additional stent
0075T	Unlisted endovascular procedure (listed in NMN coding)
0076T	Unlisted endovascular procedure (listed in NMN coding)
C7532	Stent placement, intracranial, excluding carotid (listed in NMN coding)

Provider Actions & Administrative Requirements

Documentation Required

Benefit verification required

Confirm member's specific health benefit plan terms and whether endovascular therapy is a covered benefit; policy existence does not guarantee coverage.

Prior Authorization

Preauthorization / benefit determination risk

Obtain prior authorization or contact Capital Blue Cross Provider/Member Services to determine benefit applicability, since coverage is subject to member's plan language and product variations.

Because this policy is retired effective 4/1/2025 and cardiac services have been delegated to TurningPoint, authorization workflows and routing may have changed. Providers and plans should verify current prior authorization and routing procedures with the member's health plan or contact Provider/Member Services or TurningPoint for up-to-date authorization instructions.

Background, Evidence & Definitions

Endovascular therapies for extracranial vertebral artery disease have been investigated because open surgical access to the vessel origin is technically difficult. Endovascular treatment commonly consists of percutaneous transluminal angioplasty, with or without stent implantation, and various carotid- or coronary-approved stents (self- or balloon-expandable) have been used off-label for vertebral artery lesions. No devices are FDA-approved specifically for extracranial vertebral artery disease.

Randomized trials (VIST, VAST) and pooled analyses informed the clinical trial context; nonrandomized studies and registries document feasibility and technical success but provide limited long-term comparative effectiveness data.

Evidence source	Summary
Randomized trials	VIST and VAST did not demonstrate clear benefit of vertebral artery stenting vs medical therapy.
Registry / case series	Noncomparative studies show technical success but limited long-term data and high in-stent restenosis rates.

Definitions

Extracranial vertebral arterySegments V1-V3: from origin at the subclavian artery until the vessel crosses the dura mater.

Medicare Determinations

Year	Name	NCD Number	Type
2013	Percutaneous Transluminal Angioplasty (PTA)	20.7	NCD

Revision History

05/12/2021policy_change

Changed statement from investigational to not medically necessary; background, rationale, and references updated.

11/29/2022administrative_update

Administrative update adding procedure code C7532 effective 1/1/2023.

04/01/2025retirementLatest

Policy retired effective 4/1/2025; Retirement Review 01/24/2025 noted and cardiac services delegated to TurningPoint.