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CurrentCurativePolicy CHP-IP-2026-113

Abdominal Aortic Aneurysm Repair (Open and Endovascular)

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Curative commercial PPO and EPO coverage for inpatient admission, level-of-care assignment, continued stay, and discharge after open or endovascular repair of abdominal aortic aneurysms and associated abdominal aortic dissection repair in adults age 18 and older.

Policy Summary

PayerCurative

PolicyAbdominal Aortic Aneurysm Repair (Open and Endovascular)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateNovember 5, 2026

Next Review DateN/A

Key ActionSubmit the diagnosis, indication, objective supporting findings and imaging, planned procedure, daily progress information, discharge readiness, and follow-up plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5.5/5.0 cmElective repair threshold

1-2 daysUncomplicated standard EVAR stay

5-8 daysOpen repair stay

24 hoursConcurrent review

20 mm HgCompartment syndrome threshold

Inpatient Coverage Criteria

Initial inpatient admission

Inpatient admission is medically necessary when ALL of the following are met.

Required inpatient admission criteria

Procedure indications met
- Indication: Ruptured abdominal aortic aneurysm requiring emergency repair; EVAR is preferred when anatomy allows.
- Indication: Symptomatic intact aneurysm of any size requiring urgent repair.
- Indication: Asymptomatic fusiform aneurysm at least 5.5 cm in a man or at least 5.0 cm in a woman.>=5.5 cm in men; >=5.0 cm in women

Policy Summary

PayerCurative

PolicyAbdominal Aortic Aneurysm Repair (Open and Endovascular)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateNovember 5, 2026

Next Review DateN/A

Key ActionSubmit the diagnosis, indication, objective supporting findings and imaging, planned procedure, daily progress information, discharge readiness, and follow-up plan.

SourceLink

On This Page

Indication: Aneurysm growth of at least 0.5 cm in 6 months or at least 1.0 cm in 1 year.>=0.5 cm in 6 months or >=1.0 cm in 1 year

Indication: Saccular aneurysm, mycotic aneurysm, or aneurysm with distal embolization.

Indication: Type I or III endoleak, type II endoleak with sac growth of at least 0.5 cm, or limb occlusion after prior EVAR requiring open conversion or endovascular revision with inpatient monitoring.Type II endoleak with sac growth >=0.5 cm

Inpatient setting required

Setting requirement: Open repair of any type.
Setting requirement: Ruptured or symptomatic aneurysm, or fenestrated or branched EVAR.
Setting requirement: Standard EVAR requiring overnight monitoring of access sites, renal function, and limb perfusion.Overnight monitoring
Setting requirement: ASA physical status III or higher, chronic kidney disease with contrast exposure, or spinal drain placement.ASA >= III

Observation or outpatient instead of inpatient

Outpatient or observation care is appropriate when ANY of the following applies and no inpatient criterion is met.

Outpatient or observation pathway

Surveillance: Asymptomatic aneurysm below the repair threshold managed with surveillance imaging, such as imaging every 12 months for a 4.0 to 4.9 cm aneurysm.4.0-4.9 cm example; generally every 12 months
Post-EVAR surveillance imaging or treatment of a stable type II endoleak without sac growth.No sac growth

Intensive care unit

ICU care is appropriate when ANY of the following is present.

ICU criteria

Postoperative timing: First 24 hours after open repair or after repair of a ruptured aneurysm by any approach.First 24 hours
Critical support: Mechanical ventilation, vasopressor requirement, or massive transfusion.
Major complication: Abdominal compartment syndrome, colonic ischemia, or acute kidney injury requiring continuous renal replacement therapy.Bladder pressure >20 mm Hg with new organ dysfunction for abdominal compartment syndrome
Neurologic or spinal protection: Spinal drain in place for spinal cord protection or new lower-extremity paralysis.

Step-down or intermediate care

Step-down or intermediate care is appropriate when ANY of the following is present and no ICU criterion is met.

Step-down criteria

Post-open repair monitoring: After the first 24 hours following open repair, with telemetry and hourly to two-hourly distal pulse checks.After first 24 hours; pulse checks every 1-2 hours
Complex EVAR monitoring: After fenestrated or branched EVAR with renal or visceral branch monitoring.
Blood pressure management: Blood pressure control requiring IV antihypertensives.

Medical-surgical unit

Medical-surgical care is appropriate when ANY of the following applies and no higher-level criterion is met.

Medical-surgical criteria

Standard EVAR recovery: Uncomplicated standard EVAR overnight with access-site and pulse checks every 2 to 4 hours.Pulse checks every 2-4 hours
Open repair recovery with diet advancement and mobilization.

Discharge readiness

The member is ready for discharge from acute inpatient care when ALL of the following are met.

Hemodynamic and temperature stability: Hemodynamically stable without IV vasoactive medication for at least 24 hours and temperature below 38.0 C for at least 24 hours, or a documented non-infectious explanation.24 hours; temperature <38.0 C
Pain controlled on an oral or other regimen that can continue after discharge.
Nutrition: Tolerating oral intake or has a stable enteral or parenteral nutrition plan deliverable at the next level of care.
Wounds, drains, and tubes are stable, with a documented management plan that the patient, caregiver, or home-health agency can carry out.
Mobility is at the expected post-procedure level or there is a safe plan at the receiving level of care.
Laboratory stability: Laboratory values are stable or improving with no result requiring inpatient intervention.
Discharge planning: Venous thromboembolism prophylaxis plan, medication reconciliation, surgeon follow-up date, and return precautions are documented.
Vascular examination: Distal pulses or Doppler signals are at baseline and access sites have no expanding hematoma.
Renal function: Creatinine is stable or improving after contrast exposure.
Secondary prevention and surveillance: Antiplatelet and statin therapy are prescribed and post-EVAR surveillance imaging is scheduled, generally at 1 month.Generally 1 month for post-EVAR imaging

Continued inpatient stay

Continued inpatient stay is medically necessary when reviewed at least every 24 hours and ANY of the following is documented.

Continued-stay criteria

Unresolved instability: Hemodynamic, respiratory, or neurologic instability remains unresolved, including any ICU or step-down criterion that is still present.
Active postoperative complication: Bleeding requiring transfusion or return to the operating room; surgical-site infection requiring IV antibiotics or drainage; venous thromboembolism requiring initiation of therapeutic anticoagulation with monitoring; acute kidney injury with rising creatinine; or ileus requiring nasogastric decompression.
Non-transferable IV therapy: IV antibiotics have not transitioned, parenteral nutrition is being initiated, or IV analgesia has not been converted to a lower-level regimen.
Pending urgent procedure: An urgent procedure or re-intervention is scheduled within 24 hours.Within 24 hours
Ischemia under active management: Colonic ischemia, limb ischemia, or spinal cord ischemia is under active management.
Renal deterioration: Acute kidney injury with rising creatinine or new dialysis.

Expected length of stay and extended-stay review

Days beyond the expected benchmark require documentation of the trigger, objective evidence, and targeted plan; benchmark length of stay alone is not a coverage limit.

Extended-stay triggers

Extended-stay circumstance: Colonic ischemia, limb ischemia requiring further intervention, compartment syndrome requiring fasciotomy, rhabdomyolysis with acute kidney injury, spinal cord ischemia, graft infection, ruptured aneurysm recovery, or respiratory failure.

Does not meet criteria

The following scenarios do not meet medical-necessity criteria and are referred for physician review rather than automated denial.

Below threshold: Elective repair of an asymptomatic fusiform aneurysm below 5.5 cm in a man or 5.0 cm in a woman without rapid growth.<5.5 cm in men; <5.0 cm in women
Surveillance is recommended.
Unjustified post-EVAR stay: Hospital stay beyond postoperative day 1 after uncomplicated standard EVAR without a continued-stay criterion.Beyond postoperative day 1
Preoperative convenience admission: Preoperative admission more than one day before surgery for scheduling, transportation, or routine testing that can be completed as an outpatient, absent documented medical optimization requiring inpatient preparation.More than 1 day before surgery
Stay after discharge readiness: Continued postoperative stay when all discharge-readiness criteria are met.
Placement delay: Continued stay solely while awaiting skilled nursing, inpatient rehabilitation, or long-term acute-care placement after medical readiness is documented.
Already-authorized days are not retroactively denied.
Elective post-discharge testing: Days added only for elective testing or consultation that could be completed as an outpatient after discharge.

This policy does not address thoracic or thoracoabdominal aortic repair, carotid endarterectomy, peripheral bypass, or amputation. These procedures are reviewed under other applicable policies.

An asymptomatic aneurysm below the repair threshold managed with surveillance imaging—such as imaging generally performed every 12 months for a 4.0–4.9 cm aneurysm—is not an inpatient repair indication when no other inpatient criterion is met.

Post-EVAR surveillance imaging or outpatient treatment is appropriate for a stable type II endoleak without sac growth when no inpatient criterion is met.

The following scenarios do not meet medical-necessity criteria and are referred for physician review: elective repair below 5.5 cm in men or 5.0 cm in women without rapid growth; a stay beyond postoperative day 1 after uncomplicated standard EVAR without a continued-stay criterion; preoperative admission more than one day before surgery for scheduling, transportation, or routine outpatient testing; continued stay after discharge readiness; placement-only delay after medical readiness; or days added solely for elective testing or consultation that could occur after discharge.

Diagnosis, Procedure, and Utilization Coding

ICD-10-CM abdominal aortic aneurysmICD-10

I71.30	Abdominal aortic aneurysm, ruptured or without rupture, by location
I71.31	Abdominal aortic aneurysm, ruptured or without rupture, by location
I71.32	Abdominal aortic aneurysm, ruptured or without rupture, by location
I71.33	Abdominal aortic aneurysm, ruptured or without rupture, by location
I71.40	Abdominal aortic aneurysm, ruptured or without rupture, by location
I71.41	Abdominal aortic aneurysm, ruptured or without rupture, by location
I71.42	Abdominal aortic aneurysm, ruptured or without rupture, by location
I71.43	Abdominal aortic aneurysm, ruptured or without rupture, by location

ICD-10-CM aortic dissectionICD-10

I71.00	Aortic dissection
I71.010	Aortic dissection
I71.011	Aortic dissection
I71.012	Aortic dissection
I71.019	Aortic dissection
I71.02	Aortic dissection
I71.03	Aortic dissection

ICD-10-CM statusICD-10

Z95.828

Status

ICD-10-PCS abdominal aorta proceduresICD-10

04R007Z	Replacement, restriction, and supplement of abdominal aorta
04R00JZ	Replacement, restriction, and supplement of abdominal aorta
04R00KZ	Replacement, restriction, and supplement of abdominal aorta
04V00CZ	Replacement, restriction, and supplement of abdominal aorta
04V00DJ	Replacement, restriction, and supplement of abdominal aorta
04V00DZ	Replacement, restriction, and supplement of abdominal aorta
04V00EZ	Replacement, restriction, and supplement of abdominal aorta
04V00FZ	Replacement, restriction, and supplement of abdominal aorta
04V00ZZ	Replacement, restriction, and supplement of abdominal aorta
04V03CZ	Replacement, restriction, and supplement of abdominal aorta

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CPT endovascular repair, extensionsCPT

34701	Endovascular repair, extensions
34702	Endovascular repair, extensions
34703	Endovascular repair, extensions
34704	Endovascular repair, extensions
34705	Endovascular repair, extensions
34706	Endovascular repair, extensions
34707	Endovascular repair, extensions
34708	Endovascular repair, extensions
34709	Endovascular repair, extensions
34710	Endovascular repair, extensions

1–10 of 11

1/2

CPT fenestrated endovascular repairCPT

34841	Fenestrated endovascular repair
34842	Fenestrated endovascular repair
34843	Fenestrated endovascular repair
34844	Fenestrated endovascular repair
34845	Fenestrated endovascular repair
34846	Fenestrated endovascular repair
34847	Fenestrated endovascular repair
34848	Fenestrated endovascular repair

CPT open aneurysm repairCPT

35081	Open aneurysm repair, infrarenal, ruptured, visceral, or iliac involvement
35082	Open aneurysm repair, infrarenal, ruptured, visceral, or iliac involvement
35091	Open aneurysm repair, infrarenal, ruptured, visceral, or iliac involvement
35092	Open aneurysm repair, infrarenal, ruptured, visceral, or iliac involvement
35102	Open aneurysm repair, infrarenal, ruptured, visceral, or iliac involvement
35103	Open aneurysm repair, infrarenal, ruptured, visceral, or iliac involvement

MS-DRG FY2027 v44Revenue

213	Endovascular abdominal aorta with iliac branch procedures
268	Aortic and heart assist procedures except pulsation balloon
269	Aortic and heart assist procedures except pulsation balloon
270	Other major cardiovascular procedures
271	Other major cardiovascular procedures
272	Other major cardiovascular procedures

Revenue codes (facility)Revenue

0110	Room and board
0111	Room and board
0112	Room and board
0113	Room and board
0114	Room and board
0115	Room and board
0116	Room and board
0117	Room and board
0118	Room and board
0119	Room and board

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Abdominal aortic aneurysm diagnosesICD-10

I71.30	abdominal aortic aneurysm, ruptured and without rupture (by location)
I71.31	abdominal aortic aneurysm, ruptured and without rupture (by location)
I71.32	abdominal aortic aneurysm, ruptured and without rupture (by location)
I71.33	abdominal aortic aneurysm, ruptured and without rupture (by location)
I71.40	abdominal aortic aneurysm, ruptured and without rupture (by location)
I71.41	abdominal aortic aneurysm, ruptured and without rupture (by location)
I71.42	abdominal aortic aneurysm, ruptured and without rupture (by location)
I71.43	abdominal aortic aneurysm, ruptured and without rupture (by location)

Aortic dissection diagnosesICD-10

I71.00	aortic dissection
I71.010	aortic dissection
I71.011	aortic dissection
I71.012	aortic dissection
I71.019	aortic dissection
I71.02	aortic dissection
I71.03	aortic dissection

Status diagnosisICD-10

Z95.828

status

Abdominal aorta replacement, restriction, and supplementICD-10

04R007Z	replacement, restriction, and supplement of abdominal aorta
04R00JZ	replacement, restriction, and supplement of abdominal aorta
04R00KZ	replacement, restriction, and supplement of abdominal aorta
04V00CZ	replacement, restriction, and supplement of abdominal aorta
04V00DJ	replacement, restriction, and supplement of abdominal aorta
04V00DZ	replacement, restriction, and supplement of abdominal aorta
04V00EZ	replacement, restriction, and supplement of abdominal aorta
04V00FZ	replacement, restriction, and supplement of abdominal aorta
04V00ZZ	replacement, restriction, and supplement of abdominal aorta
04V03CZ	replacement, restriction, and supplement of abdominal aorta

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1/4

Endovascular repair, extensionsCPTCovered

34701	endovascular repair, extensions
34702	endovascular repair, extensions
34703	endovascular repair, extensions
34704	endovascular repair, extensions
34705	endovascular repair, extensions
34706	endovascular repair, extensions
34707	endovascular repair, extensions
34708	endovascular repair, extensions
34709	endovascular repair, extensions
34710	endovascular repair, extensions

1–10 of 11

1/2

Fenestrated endovascular repairCPTCovered

34841	fenestrated endovascular repair
34842	fenestrated endovascular repair
34843	fenestrated endovascular repair
34844	fenestrated endovascular repair
34845	fenestrated endovascular repair
34846	fenestrated endovascular repair
34847	fenestrated endovascular repair
34848	fenestrated endovascular repair

Open aneurysm repairCPTCovered

35081	open aneurysm repair (infrarenal, ruptured, visceral, iliac involvement)
35082	open aneurysm repair (infrarenal, ruptured, visceral, iliac involvement)
35091	open aneurysm repair (infrarenal, ruptured, visceral, iliac involvement)
35092	open aneurysm repair (infrarenal, ruptured, visceral, iliac involvement)
35102	open aneurysm repair (infrarenal, ruptured, visceral, iliac involvement)
35103	open aneurysm repair (infrarenal, ruptured, visceral, iliac involvement)

MS-DRG (FY2027 v44)mixed

213	MS-DRG
268	MS-DRG
269	MS-DRG
270	MS-DRG
271	MS-DRG
272	MS-DRG

Revenue codes (facility)Revenue

0110	room and board
0111	room and board
0112	room and board
0113	room and board
0114	room and board
0115	room and board
0116	room and board
0117	room and board
0118	room and board
0119	room and board

1–10 of 36

1/4

Elective asymptomatic aneurysm repair threshold in men

Threshold for men5.5 cm or larger

PopulationMen with an asymptomatic fusiform abdominal aortic aneurysm

Repair contextElective repair meets the size-based indication when the aneurysm is 5.5 cm or larger

Elective asymptomatic aneurysm repair threshold in women

Threshold for women5.0 cm or larger

PopulationWomen with an asymptomatic fusiform abdominal aortic aneurysm

Repair contextElective repair meets the size-based indication when the aneurysm is 5.0 cm or larger

Rapid aneurysm growth

Six-month thresholdAneurysm enlargement of 0.5 cm or more in 6 months

One-year thresholdAneurysm enlargement of 1.0 cm or more in 1 year

Imaging requirementGrowth is assessed on comparable imaging

Abdominal compartment syndrome bladder pressure

Bladder-pressure thresholdAbove 20 mm Hg

Required associated findingNew organ dysfunction

Care implicationAbdominal compartment syndrome meeting these findings supports ICU-level care

Concurrent review interval

Concurrent review frequencyEvery 24 hours

Review typeConcurrent review during the inpatient stay

Additional physician review triggerWhen the stay exceeds the benchmark by 2 days or more without a documented extended-stay trigger

Documentation and Review Actions

Documentation Required

Submit complete clinical and utilization documentation

Submit the diagnosis, indication, and objective supporting findings and imaging, along with the planned procedure, approach, urgency, and device type. Include ASA physical status class, relevant comorbidities, the reason inpatient care is required, daily progress information, level-of-care justification, discharge readiness, destination, follow-up plan, CT angiography details, prior imaging when growth is the indication, symptoms when present, and the choice of open versus endovascular repair.

CT angiography: maximum aneurysm diameter, morphology, neck anatomy, and iliac access.
Daily progress: vital signs, drains/tubes and outputs, pain control, diet, mobility, laboratory values, and complications.
For ICU or step-down days, document the objective reason for that level of care.

Documentation Required

Support the requested amount

Documentation must support the requested quantity, units, and duration of service. Unsupported increments are reviewed separately.

Denial Risk

Document an indication for repair below the size threshold

Elective repair of an asymptomatic fusiform aneurysm below 5.5 cm in a man or 5.0 cm in a woman without rapid growth does not meet medical-necessity criteria; surveillance is recommended. Such requests are referred for physician review.

Men: repair threshold is 5.5 cm.
Women: repair threshold is 5.0 cm.
Document rapid growth when applicable: at least 0.5 cm in 6 months or at least 1.0 cm in 1 year.

Denial Risk

Support continued stay after standard EVAR

A hospital stay beyond postoperative day 1 after uncomplicated standard EVAR does not meet medical-necessity criteria unless a continued-stay criterion is documented. The request is referred for physician review.

Document an unresolved acute inpatient need, such as instability, an active postoperative complication, non-transferable IV therapy, an urgent procedure within 24 hours, active ischemia management, or renal deterioration.
Concurrent review applies to each continued-stay period.

Denial Risk

Avoid non-medical preoperative admission

Preoperative admission for more than one day for scheduling, transportation, or routine testing that can be completed as an outpatient is not medically necessary. Admit on the day of surgery unless documented medical optimization requires inpatient preparation.

Examples of documented medical optimization include IV heparin bridging, IV hydration, or bowel preparation in a patient who cannot tolerate it at home.

Denial Risk

Discharge when medically ready

Continued postoperative days are not medically necessary when all discharge-readiness criteria are met, when the member is medically ready but awaiting placement, or when days are added solely for elective testing or consultation that could occur after discharge. Route placement-only delays to physician review and case management; already-authorized days are never retroactively denied.

Document unresolved acute needs when discharge readiness criteria are not met.
Elective testing or consultation must change acute management to support continued inpatient care.

Note

Requests that do not meet criteria require physician review

A request that does not meet the applicable coverage criteria is referred to a physician for review before an adverse determination may be issued. Automated systems and non-physician clinical reviewers may not issue an adverse determination.

Only a licensed physician of the same or similar specialty may issue an adverse determination after offering the requesting provider a peer-to-peer discussion.

Denial Risk

Limit approval to the supported amount

When the requested quantity, units, or duration exceed what the documentation supports, approve only the supported portion; the unsupported increment is subject to review. Document the clinical basis for the amount requested.

The supported portion may be approved in full or in part.
Only the unsupported increment is reviewed.

Clinical Background

Society for Vascular Surgery and ACC/AHA guidance supports elective abdominal aortic aneurysm repair at 5.5 cm or larger in men and 5.0 cm or larger in women. Repair is also supported for rapid aneurysm growth, attributable symptoms, or rupture. Smaller asymptomatic aneurysms are generally managed with surveillance imaging.

Clinical Definitions

Rapid growth

Comparable-imaging thresholdAneurysm enlargement of 0.5 cm or more in 6 months

One-year thresholdAneurysm enlargement of 1.0 cm or more in 1 year

ACC/AHA criterionACC/AHA identifies enlargement of 0.5 cm or more per year as a 2a indication

Symptomatic aneurysm

Pain or tendernessAbdominal or back pain or tenderness attributable to the aneurysm

Distal embolizationDistal embolization associated with the aneurysm

RuptureAneurysm rupture