RetiredCareFirstPolicy 7.01.009

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Defines clinical indications, follow-up guidelines, and archival status for coverage of the transjugular intrahepatic portosystemic shunt procedure for CareFirst members.

Policy Summary

PayerCareFirst

PolicyTransjugular Intrahepatic Portosystemic Shunt (TIPS)

Policy CodePolicy 7.01.009

Change TypeArchived

Effective Date

Next Review Date

Key ActionRecommend sonographic surveillance within 24 hours of insertion, at 3–6 month intervals for the first year, and at 6–9 month intervals thereafter to monitor for shunt closure.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

archivedpolicy status as of 9/6/02

3medically necessary uses

sonogram intervalssurveillance schedule

09/06/2002last review

Coverage Criteria for TIPS

Medically Necessary Indications

TIPS is considered medically necessary for, but not limited to, the following indications:

Indication A: acute variceal bleeding that cannot be successfully controlled with medical treatment or sclerotherapy

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Indication B: recurrent variceal bleeding in patients who are resistant to, or intolerant of, conventional medical management, sclerotherapy, or pharmacologic therapy

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Indication C: patients with end-stage liver disease who are active candidates for liver transplants and who require bleeding control from esophageal varices

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This policy was archived effective 9/6/02. Per the archived notice, the policy’s application is no longer limited by the diagnoses listed in the policy and the document is not scheduled for further review. This means diagnostic listings in the original policy should not be interpreted as current restrictions on use.

Policy Summary

PayerCareFirst

PolicyTransjugular Intrahepatic Portosystemic Shunt (TIPS)

Policy CodePolicy 7.01.009

Change TypeArchived

Effective Date

Next Review Date

Key ActionRecommend sonographic surveillance within 24 hours of insertion, at 3–6 month intervals for the first year, and at 6–9 month intervals thereafter to monitor for shunt closure.

SourceLink

On This Page

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Provider Actions and Follow-up

Note

Policy Archived — No Action Required

Not applicable — policy archived as of 9/6/02; no provider actions or prior authorization requirements apply. The application of this policy is no longer limited by the diagnoses listed and the policy is no longer scheduled for review.

Archived date: 9/6/02

Note

Therapeutic Pathway (Archived Guidance)

TIPS remains a treatment option historically indicated after failure of medical therapy, sclerotherapy, or pharmacologic therapy for variceal bleeding, and for select liver transplant candidates requiring bleeding control. Although the policy is archived (no active prior authorization rules), clinicians should follow current clinical standards and any applicable payer-specific authorization processes that may supersede archived guidance.

Clinical pathway note: TIPS indicated after failure of medical/sclerotherapy/pharmacologic therapy.
Active prior authorization: None specified in archived policy

Note

Post-procedure Surveillance (Historic)

Post-procedure surveillance historically recommended: sonographic evaluation within 24 hours of shunt insertion, then at 3–6 month intervals during the first year, and at 6–9 month intervals thereafter to monitor for shunt patency and tendency to shunt closure.

Surveillance schedule: within 24 hours; 3–6 months during first year; then every 6–9 months thereafter.

OpenPayer

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Coverage Criteria for TIPS

Provider Actions and Follow-up

Background

Definitions