Prior authorization: timing and required contents

Submit prior-authorization requests at least two weeks before the anticipated date of elective surgery and include all required clinical and imaging documentation listed in the policy (proposed procedure, condition treated, conservative therapy details, prior interventions, aneurysm measurements, nature of CLI, and recent imaging and clinical evaluation).

• Submit requests ≥2 weeks prior to elective surgery.
• Include proposed procedure, condition treated, detailed conservative therapy (duration/frequency/response), prior intervention details, aneurysm location/size when present, description of CLI if applicable, and recent (within 6 months) diagnostic imaging and clinical evaluation (symptoms and exam including ulcer location/size).

Prior authorization must document applicable clinical criteria

Demonstrate that the patient meets the clinical revascularization criteria appropriate to the procedure requested; if CAS/TCAR is proposed, include documentation of the high‑risk features for CEA or other specified indications (e.g., failed medical therapy and degree of stenosis for vertebral stenting).

• Show patient meets revascularization criteria (symptom thresholds, stenosis thresholds per the applicable section).
• For CAS/TCAR, include documented high‑risk CEA features listed in the policy.
• For vertebral artery stenting, document failure of antiplatelet/anticoagulation therapy, exclusion/treatment of non‑vascular causes, ongoing symptoms, and 60–99% stenosis when applicable.

CPT 34717: include concomitant AAA and aneurysm measurements

When requesting CPT 34717 (iliac branched endograft), include documentation that concomitant endovascular AAA repair is planned and that ipsilateral common iliac aneurysm diameter and contralateral internal iliac artery status meet the policy criteria.

• Document planned concomitant endovascular AAA repair.
• Document ipsilateral common iliac artery aneurysm diameter >3.5 cm.
• Document contralateral internal iliac artery occlusion when applicable.

Prior authorization required for listed CPT procedures

Prior authorization is required or expected for the endovascular visceral and peripheral CPT codes enumerated in the policy; include the specific CPT(s) for the planned procedure in the request and supporting documentation of indication.

• Use the listed CPT codes for embolization, angioplasty, stent placement, atherectomy, and intravascular lithotripsy when submitting authorization.
• Attach clinical and imaging documentation supporting the coded procedure.

IVL HCPCS billing: include clinical and imaging justification

When intravascular lithotripsy HCPCS codes (C9764, C9765, C9766, C9775) are billed, ensure the prior-authorization request includes clinical justification and imaging documentation supporting use of IVL per policy criteria.

• Cite the appropriate HCPCS code for IVL being billed.
• Document CLI or other qualifying indication plus imaging evidence of ≥50% stenosis/occlusion due to moderate or severe calcified plaque in the treated arterial territory.

Lower-extremity CPTs: use correct codes with supporting documentation

When submitting authorization or claims for lower-extremity revascularization, use the enumerated lower‑extremity CPT codes and include supporting documentation that meets the policy's clinical and imaging thresholds.

• Select the correct CPT(s) from the lower‑extremity angioplasty/stent/atherectomy/IVL groups.
• Provide imaging confirming lesion location and stenosis degree (e.g., ≥50% when required) and documentation of prior conservative therapy when applicable.

Authorization must meet documented clinical and imaging thresholds

Authorization requests must document that the individual meets the policy's clinical and imaging thresholds for initial or repeat intervention (symptoms, prior conservative therapy where required, and objective imaging such as duplex/CTA/MRA/angiogram confirming the required percent stenosis or PSV thresholds).

• For claudication, document failed 3‑month structured conservative therapy and imaging confirming ≥50% stenosis.
• For CLI/IVL, document CLI features and imaging demonstrating ≥50% stenosis or calcified lesion per IVL criteria.
• For surveillance/re‑intervention, include ABI/TBI, duplex PSV or velocity ratios as required.

Endovenous ablation PA: include CEAP/VCSS, recent duplex, and CPTs

For endovenous ablation and related saphenous vein procedures, include CEAP or VCSS scores, a venous duplex within 6 months demonstrating pathologic reflux (≥500 ms) in the required segments, and the specific CPT codes for the planned ablation in the authorization request.

• Provide CEAP ≥2 OR VCSS ≥6.
• Attach venous duplex (within 6 months) demonstrating reflux ≥500 ms in required segments.
• List the planned CPT(s) for endovenous ablation (e.g., 36475/36476/36478/36473/36482) and any concurrent procedures.

Prior authorization for foam sclerotherapy CPTs (36465/36466)

Prior authorization is required for foam sclerotherapy CPTs (36465 for single truncal vein; 36466 for multiple truncal veins same leg) and must demonstrate that all clinical, duplex, and time/volume criteria for non‑compounded foam sclerotherapy are met.

• Cite CPT 36465 or 36466 as applicable.
• Provide CEAP ≥2 OR VCSS ≥6 and duplex showing truncal reflux ≥500 ms per segment rules.
• Limit treatments to no more than two saphenous veins within a 12‑week period except for venous ulcers.

PA required for phlebectomy/high ligation/stripping and related codes

Prior authorization is required for listed CPTs for phlebectomy, high ligation/stripping, perforator surgery, and sclerosant injections; include symptom severity, recent duplex or size measurements, and rationale for open procedures in the request.

• Include CEAP ≥2 OR VCSS ≥6 and recent duplex or objective size measurement (within 6 months).
• For phlebectomy/high ligation, document tributary size (≥6 mm or ≥3 mm with ≥500 ms reflux) and any required observation period or concurrent treatment plan.
• For open procedures, include clinical justification and applicable CPT(s) (e.g., 37700, 37718, 37722, 37735, 37765/37766/37780).

PA expected for venous angioplasty/stenting; include stenosis and symptom evidence

Prior authorization is expected for iliac/IVC and upper‑extremity venous angioplasty and stenting (including hemodialysis outflow procedures); include imaging demonstrating the percent stenosis threshold and clinical signs/symptoms supporting the intervention.

• Document imaging demonstrating ≥50% stenosis (or >60% diameter for specified NIVL) on US/MRV/CTV/venography/IVUS as applicable.
• For hemodialysis outflow, document clinical indicators (arm edema, inadequate dialysis performance, loss of thrill, etc.).
• List CPT(s) for venous angioplasty/stent (e.g., 37238/37239/37248/37249) in the request.

Venous interventions: PA implied when stenosis and symptom criteria met

When venous angioplasty/stenting indications are met (e.g., >50% stenosis with relevant clinical signs), prior authorization is implied; ensure the request cites the specific indication, imaging percent stenosis, and failed conservative therapy where required.

• Cite imaging showing >50% stenosis and clinical correlation (edema, ulceration, venous claudication) as applicable.
• For SVC or pulmonary/pulmonary vein cases, include the imaging thresholds (SVC >50%; pulmonary vein ≥60% or 4–6 mm on advanced imaging).
• Document prior conservative therapy attempts where the policy requires them (e.g., 8 weeks for selected NIVL).

Embolization CPTs (37241–37244): include codes and indication in PA

Include the embolization CPT group (37241–37244) in authorization requests for embolization/occlusion procedures and cite the applicable indication supported by imaging and clinical documentation.

• Select the appropriate embolization CPT (37241–37244) matching the procedure.
• Attach imaging and clinical documentation demonstrating the indication (aneurysm size, hemorrhage source, tumor, varicocele, pelvic congestion criteria, etc.).

PA required for embolization: cite specific indication and supporting data

Prior authorization is expected for embolization procedures; the request should cite the specific listed indication (e.g., varicocele with palpable finding and infertility, ovarian vein embolization meeting pelvic congestion criteria, oncologic embolization indications) and include required imaging and clinical documentation.

• For varicocele embolization, document palpable varicocele or ultrasound confirmation and linkage to infertility or recurrent varicocele.
• For ovarian vein embolization, provide chronic pelvic pain >6 months, symptom descriptors, exclusion of inflammatory disease, and pelvic imaging meeting diameter/flow thresholds.
• For oncologic embolization, provide tumor-specific imaging and indication (e.g., HCC chemoembolization).

Bibliography contains no prior-authorization instructions

No prior-authorization requirements are stated in the bibliography section of the policy excerpt; do not rely on the bibliography for authorization instructions.

• Bibliography entries do not specify authorization procedures.

Urgent/emergent exception to conservative management

Urgent or emergent conditions (e.g., critical limb ischemia, symptomatic carotid stenosis, crescendo TIAs, symptomatic or ruptured aneurysms) do not require prior conservative therapy and should be processed under urgent/emergent review.

• Document the urgent/emergent condition and supporting imaging/clinical assessment.
• Provider-directed non‑surgical management is not required in these settings.

Therapy escalation required before vertebral stenting

Before vertebral artery stenting, document failure of antiplatelet or anticoagulation therapy, exclusion/treatment of non‑vascular etiologies, and ongoing posterior circulation symptoms plus imaging demonstrating the required degree of stenosis per policy.

• Document attempted medical therapy and lack of response.
• Document imaging confirming 60–99% vertebral artery stenosis when indicated and clinical symptom correlation.

Step therapy / staging: document justification for staged procedures

The policy acknowledges intraoperative decision-making and multi‑level disease but does not specify explicit staged‑therapy requirements; document clinical justification when staging is performed.

• Valid reasons for staging must be documented (patient instability, excessive fluoroscopy, conversion to general anesthesia without resources, contrast >200 mL).
• Lack of documented justification for staging may risk denial.

Conservative therapy required for claudication (3 months)

For lifestyle‑limiting claudication, include documentation of a failed trial of three months of provider‑directed conservative therapy (structured exercise walking program or documented alternative) before authorization for intervention.

• Document duration and content of conservative therapy and objective follow‑up.
• Show functional limitation and risk‑factor modification efforts as part of the evaluation.

Document conservative therapy trials prior to venous interventions

Conservative medical management (leg elevation, exercise, compression, weight loss where applicable) is expected as initial therapy for many venous conditions; document the trial and response when intervention is requested.

• Describe conservative measures attempted and duration.
• For certain venous indications (e.g., NIVL, SVC syndrome), document required conservative trials (e.g., 8 weeks for selected NIVL; head elevation/diuretics/anticoagulation for SVC).

Timing/staged treatment for varicosities with saphenous reflux

When varicosities are associated with saphenous reflux, treatment may be performed concurrently with saphenous ablation or after a 12‑week observation following ablation (observation not required for venous ulcers); document timing and rationale in the request.

• If treating tributaries concurrently, document plan to treat them at the time of saphenous ablation.
• If staged, document the 12‑week observation and persistent symptoms if applicable.

Conservative therapy trial (≥8 weeks) required for selected NIVL indications

For selected non‑thrombotic iliac lesions, document an ≥8‑week trial of conservative therapy (graded compression stockings, weight loss if applicable) and lack of improvement before intervention when the policy requires it.

• Document the conservative measures, duration (≥8 weeks), and outcome (no improvement, worsening, or limited improvement with persistent lifestyle‑limiting symptoms).

Conservative therapy required before SVC stenting

Conservative measures (head elevation, diuretics, anticoagulation) should be attempted and documented as failed prior to SVC stenting in non‑malignant SVC syndrome.

• Document conservative therapies attempted and lack of symptom resolution.
• For palliative malignant SVC syndrome, stenting may be appropriate per the policy.

Conservative therapy required before certain embolization procedures

For embolization indications such as PAE or uterine artery embolization, document prior medical therapies or less invasive measures and their failure or intolerance before authorizing embolization when the policy specifies it.

• For PAE, document failure/intolerance of medical therapy and objective measures (AUA score, prostate size) as required.
• For uterine artery embolization, provide prior imaging showing leiomyomas and documentation of failed or intolerant medical therapy.

Document prior conservative care before embolization when applicable

Many embolization indications list conservative, non‑surgical therapies (medical therapy, injections, physical therapy) as standard prior management; document prior conservative care and failure where relevant to the indication.

• Provide details of non‑surgical therapies attempted (type, duration, response).
• Relate prior conservative care to the embolization indication (e.g., genicular, shoulder, prostatic embolization).

Required documentation for prior authorization requests

Include in prior-authorization requests: the proposed procedure and CPT(s); condition treated; detailed conservative treatment (duration, frequency, response); prior intervention details; aneurysm measurements; CLI nature; and recent imaging reports and clinical evaluation (symptoms and exam including ulcer details).

• List the proposed CPT code(s) and correlate to the documented indication.
• Attach recent (within 6 months) imaging reports (duplex, CTA/MRA/angiogram, ABI/TBI, IVUS) and clinical notes documenting symptoms and exam findings.

Required imaging documentation: meet policy thresholds and recency

Provide imaging documentation that meets the policy thresholds for the indication (e.g., carotid duplex/CTA/MRA/angiogram showing ≥50% symptomatic or ≥70% asymptomatic carotid stenosis within 6 months; venous duplex demonstrating reflux ≥500 ms for venous procedures).

• For carotid procedures, include imaging within 6 months and state NASCET percentages when applicable.
• For venous procedures, attach duplex showing reflux duration (≥500 ms) in specified segments within 6 months.

Clinical documentation required for iliac endograft (CPT 34717)

For CPT 34717 and related iliac aneurysm interventions, include clinical history documenting planned concomitant AAA repair, ipsilateral common iliac diameter measurements (>3.5 cm), and contralateral internal iliac artery status; for CPTs like 34718 note experimental status per policy.

• Document planned simultaneous AAA repair when requesting CPT 34717.
• Provide measured ipsilateral common iliac diameter and contralateral IIA occlusion status.
• Do not rely on CPT 34718 for coverage—policy lists it as experimental.

Imaging and clinical documentation for aneurysm indications

Provide diagnostic imaging (US, CT, MRI, angiogram) documenting aneurysm size and, for symptomatic popliteal aneurysms, presence of mural thrombus and new ischemic symptoms to support aneurysm repair or coil embolization requests.

• Attach measurements for popliteal aneurysms (asymptomatic ≥2.0 cm; symptomatic ≥1.5 cm with mural thrombus and new ischemic symptoms).
• For visceral aneurysms, include CTA/MRA/US/angiogram documenting vessel‑specific size thresholds per policy.

Pre-procedure documentation for claudication: imaging and failed conservative therapy

For claudication, include imaging that confirms lesion location and degree of stenosis (≥50%) and documentation of failed 3‑month conservative therapy and risk‑factor modification in the prior-auth packet.

• Attach imaging demonstrating ≥50% stenosis in the target arterial segment.
• Provide records of structured exercise program or alternative conservative therapy and outcomes over 3 months.

Upper-extremity documentation: symptoms plus advanced imaging/duplex

For upper‑extremity/brachiocephalic indications, document the specific symptoms (e.g., episodic dizziness, exertional arm fatigue), advanced imaging showing high‑grade stenosis/occlusion, and duplex findings such as reversal of vertebral flow when applicable.

• List symptomatic descriptors and correlate to lesion anatomy.
• Include advanced imaging and duplex reports supporting the diagnosis (reversal of vertebral flow for subclavian steal).

Required documentation to establish medical necessity (symptom correlation and objective testing)

Clinical documentation must demonstrate symptom‑anatomy correlation, prior conservative therapy for claudication (3 months structured exercise or equivalent), and imaging confirming degree of stenosis or objective measures (e.g., ABI/TBI, PAT, duplex PSV thresholds) to support medical necessity.

• Correlate symptoms to lesion location and provide objective vascular testing results.
• Provide ABI/TBI, PAT (>225 ms) or duplex/PSV values as applicable to the indication.

Required clinical and imaging documentation for venous procedures (CEAP/VCSS and duplex)

For venous procedures, provide CEAP ≥2 or VCSS ≥6 and a venous duplex within 6 months showing pathologic reflux ≥500 ms in required segments; for perforator treatment also include perforator diameter (≥3.5 mm) and relation to an active ulcer when applicable.

• Document CEAP or VCSS score in the clinical note.
• Attach venous duplex (≤6 months) demonstrating reflux ≥500 ms in specified segments.
• For perforator interventions, include duplex evidence of reflux ≥500 ms and perforator diameter ≥3.5 mm and location relative to an active venous stasis ulcer.

Endovenous ablation documentation: duplex reflux, CEAP/VCSS, and DVT exclusion

Duplex ultrasound demonstrating pathologic truncal vein reflux (reverse flow ≥500 ms) in specified vein segments and documentation of CEAP ≥2 or VCSS ≥6, plus absence of ipsilateral acute DVT or chronic multisegmental femoral‑popliteal occlusion, must be included for endovenous ablation requests.

• Provide duplex report with reflux duration and segmental location.
• State CEAP or VCSS score and confirm absence of acute ipsilateral DVT or chronic multisegmental femoral‑popliteal occlusion.

Phlebectomy/sclerotherapy documentation: CEAP/VCSS, duplex, and size measurements

Document CEAP ≥2 or VCSS ≥6, recent venous duplex (within 6 months) with measurements of reflux and vein diameter, and the size/location of varicosities/tributaries to be treated when requesting phlebectomy, sclerotherapy, or related procedures.

• Include objective measurements (varicosity ≥6 mm, or ≥3 mm with ≥500 ms reflux) and duplex data.
• Document whether tributaries will be treated concurrently or after a 12‑week observation period when applicable.

Imaging and clinical documentation required for venous stenosis interventions

For venous stenosis interventions, document imaging demonstrating percent stenosis/area reduction (US, MRV/CTV, venography or IVUS), presence of venous collaterals, clinical signs (venous stasis ulceration, advanced stasis dermatitis, venous claudication, ipsilateral edema), and results of required conservative therapy trials (e.g., ≥8 weeks where specified).

• Attach imaging quantifying stenosis (≥50% area reduction or >60% diameter stenosis where indicated) and note presence of venous collaterals.
• Document clinical manifestations (ulceration, dermatitis, claudication, edema) and conservative therapy trials with outcomes.

Imaging documentation for pulmonary and transplant vessel interventions

Provide imaging demonstrating percent stenosis (venogram, IVUS, CTA/MRA) or absolute diameter (for pulmonary veins) when requesting interventions for pulmonary, transplant, or special‑area vascular lesions.

• For pulmonary vein stenosis, include advanced imaging showing ≥60% narrowing or absolute diameter 4–6 mm, or venogram/IVUS >50%.
• For post‑transplant arterial/venous interventions, provide duplex/CT/MR/angiography documenting arterial ≥50% or venous ≥30% stenosis at anastomosis/outflow.

Required imaging and clinical documentation for visceral aneurysm and embolization requests

For visceral aneurysm/pseudoaneurysm embolization, include diagnostic imaging (CTA, MRA, US, angiogram) documenting vessel‑specific size/location criteria per the policy to support coil embolization requests.

• Attach imaging showing vessel and measured aneurysm/PSA size (e.g., hepatic ≥2.0 cm; splenic ≥3.0 cm; renal ≥3.0 cm; other vessel thresholds per policy).
• For uterine or prostatic embolization, include prior imaging and documentation of failed/intolerant medical therapy and objective clinical measures (AUA, prostate volume) when required.

Ovarian vein embolization documentation: symptoms and pelvic imaging thresholds

For ovarian vein embolization (pelvic congestion syndrome), include documentation of chronic pelvic pain >6 months, symptom descriptors, exclusion of inflammatory disease, and pelvic imaging meeting the specified diameter/flow thresholds (US or CT/MR criteria) in the authorization request.

• Document chronic pelvic pain duration (>6 months) and specific symptoms (standing‑worse pain, postcoital ache, dysmenorrhea, dyspareunia, etc.).
• Attach pelvic imaging meeting ultrasound (tortuous veins >6 mm or flow criteria) OR CT/MR criteria (four ipsilateral para‑uterine veins >4 mm or ovarian vein >8 mm).

Varicocele embolization documentation requirements

For varicocele embolization, provide documentation of a palpable varicocele or ultrasound confirmation and, when performed for infertility, linkage to infertility evaluation or recurrent varicocele documentation.

• Attach physical exam findings or ultrasound confirming varicocele.
• If for infertility, include relevant fertility evaluation documentation or rationale for intervention.

Bibliography: no authorization procedures specified

This bibliography section does not specify clinical documentation or authorization procedures; rely on the requirements in the policy body rather than bibliography citations for PA instructions.

• Bibliography entries are references only and do not substitute for documented PA requirements.

Benefit plan conflicts: confirm member's plan terms

Coverage determinations are governed by the member's specific benefit plan; requests inconsistent with plan terms may be denied—confirm plan terms when preparing authorization requests.

• If a customer's benefit plan contains exclusions or differing terms, the plan document supersedes the coverage policy.
• Review applicable benefit plan terms before submitting requests.

Non‑indication: carotid revascularization after disabling stroke

Carotid revascularization requests for individuals with a disabling stroke (modified Rankin scale ≥3) are not medically necessary and may be denied; ensure clinical notes document stroke severity and life expectancy when applicable.

• Do not request carotid revascularization for disabling stroke patients (mRS ≥3).
• For asymptomatic carotid cases, document adequate life expectancy to benefit.

Experimental procedure risk: CPT 34718 (bifurcated‑bifurcated repair)

Requests for bifurcated‑bifurcated aneurysm repair (CPT 34718) may be denied because the technique is considered experimental, investigational, and unproven per the policy.

• Do not expect coverage for CPT 34718 absent compelling evidence; policy lists it as experimental.
• If submitted, include supporting evidence but anticipate denial based on policy stance.

Denial risk if size/symptom thresholds not met

Procedures that do not meet the policy's documented size or symptom thresholds (e.g., popliteal or visceral aneurysms below the listed diameters) risk denial for lack of medical necessity; include exact measurements and symptom documentation to avoid denial.

• Provide aneurysm diameters and symptomatic findings that meet policy thresholds (e.g., popliteal asymptomatic ≥2.0 cm; symptomatic ≥1.5 cm with mural thrombus; hepatic ≥2.0 cm; splenic ≥3.0 cm; renal ≥3.0 cm).
• If thresholds are not met, expect not‑medically‑necessary determinations.

Staging interventions: document valid justification to avoid denial

Staging interventions without documented justification (patient instability, excessive fluoroscopy, conversion needs, or contrast >200 mL) is considered not medically necessary and may be denied; document valid reasons when staging is planned.

• If staging care, include the clinical rationale and specific justification in the record.
• Lack of justification for staging is a denial trigger.

Non‑indicated scenarios that may trigger denial (asymptomatic, <50% stenosis, routine below‑knee interventions)

Procedures performed in asymptomatic individuals, lesions <50% stenosis, or routine stent/atherectomy/lithotripsy in infrapopliteal/inframalleolar vessels for claudication are listed as not medically necessary and may be denied.

• Do not submit routine below‑knee interventions for claudication without meeting high‑grade lesion criteria.
• Ensure symptoms and imaging meet policy thresholds before requesting such procedures.

Denial risk: insufficient clinical or duplex documentation for venous procedures

Requests may be denied if clinical documentation does not show symptomatic venous reflux meeting CEAP/VCSS thresholds, if recent duplex (within 6 months) does not demonstrate required reflux ≥500 ms, or if ipsilateral acute DVT or chronic multisegmental femoral‑popliteal occlusion is present.

• Provide CEAP ≥2 OR VCSS ≥6 and venous duplex within 6 months demonstrating reflux ≥500 ms in required segments.
• Confirm absence of ipsilateral acute DVT or chronic multisegmental femoral‑popliteal occlusion.

Triggers for denial in venous procedure requests (duplex, CEAP/VCSS, episode limits)

Denial risk is increased if duplex does not show pathologic truncal reflux ≥500 ms in required segments, if CEAP <2 and VCSS <6, if more than two saphenous veins are treated within a 12‑week period (except ulcers), or if contraindicating ipsilateral DVT or chronic multisegmental occlusion exists.

• Limit treatment requests to two truncal veins per extremity in a 12‑week period unless treating venous ulcers.
• Ensure CEAP/VCSS and duplex criteria are met to avoid denial triggers.

Contraindicating conditions: document absence of ipsilateral acute DVT or chronic multisegmental occlusion

Absence of ipsilateral acute lower‑extremity DVT or chronic multisegmental femoral‑popliteal occlusion is a required condition for many venous procedures; presence of these contraindicating conditions should be documented and may preclude coverage.

• Confirm and document absence of ipsilateral acute DVT or chronic multisegmental femoral‑popliteal occlusion when requesting endovenous ablation, phlebectomy, or sclerotherapy.
• If such conditions are present, include clinical rationale and contraindication discussion.

Denial risk: interventions lacking imaging‑confirmed stenosis thresholds or failed conservative therapy

Interventions without imaging‑confirmed stenosis meeting policy thresholds (e.g., <50% area reduction or ≤60% diameter stenosis for iliac/IVC NIVL) or without documentation of failed conservative therapy may be denied; include quantitative imaging and trial documentation.

• Attach imaging quantifying percent stenosis or area reduction (US, MRV/CTV, venography, IVUS).
• Document conservative therapy trials and outcomes where policy requires them.

Denial risk: venous stenting with indwelling device present

Venous stenting in the presence of an indwelling device is discouraged and may lead to denial unless an alternative justification is provided; if a device is present, document why stenting is necessary and why alternatives are unsuitable.

• State presence of any indwelling catheter or device in the vein and rationale for stent placement despite device.
• Consider balloon angioplasty as preferred approach when indwelling devices are present unless clear justification for stenting is documented.

Denial risk for non‑indicated venous procedures (nutcracker, prophylactic NIVL)

Primary endovascular treatment of left renal vein compression (nutcracker syndrome) prior to surgical decompression or prophylactic NIVL treatment in the absence of DVT/edema is not medically necessary and may be denied; document prior surgical management when seeking re‑intervention.

• Do not submit angioplasty/stenting for primary nutcracker syndrome prior to surgical decompression without strong supporting justification.
• Prophylactic NIVL treatment without acute/chronic DVT or chronic edema and sequelae is not covered.

Pre‑EVAR prophylactic embolization not covered

Embolization of aortic side branches prior to EVAR to prevent Type 2 endoleak is not medically necessary and is a basis for denial; do not request prophylactic embolization for this purpose.

• Requests for prophylactic embolization of lumbar or inferior mesenteric branches to prevent Type 2 endoleak will be considered not medically necessary.
• Embolization for Type 2 endoleak with sac enlargement remains a covered indication when criteria are met.

Non‑listed embolization indications may be denied

Procedures for vascular embolization not listed in the guideline are considered not medically necessary and may be denied; limit requests to indications enumerated in the policy or provide convincing evidence if requesting an unlisted indication.

• If proposing an embolization for an indication not listed, be prepared for denial unless high‑quality supporting evidence is submitted.
• Prefer listed, supported indications in the policy when preparing authorization requests.

Bibliography contains no PA requirements — follow policy body

The bibliography section does not specify authorization requirements; authorization procedures and documentation requirements are defined in the policy body and must be followed.

• Do not use bibliography citations as a substitute for the policy's documented PA requirements.