ModifiedPremera Blue Cross of WashingtonPolicy 7.01.601

Endovascular Stent Grafts for Abdominal Aortic Aneurysms

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This policy governs when endovascular aneurysm repair using FDA-approved endoprostheses for infrarenal abdominal aortic or aorto-iliac aneurysms may be medically necessary and covered. It also identifies an investigational bifurcated-bifurcated repair technique, required clinical documentation, applicable procedure codes, and post-implantation imaging information.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyEndovascular Stent Grafts for Abdominal Aortic Aneurysms

Policy CodePolicy 7.01.601

Change TypeModified

Effective DateNovember 6, 2026

Last ReviewAug 18, 2026

Next Review DateNot specified

Key ActionSubmit office visit notes documenting the relevant history and physical examination, aneurysmal diameter, FDA-approved endoprosthesis, and at least one qualifying aneurysm condition.

SourceLink

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ModifiedPremera Blue Cross of WashingtonPolicy 7.01.601

Endovascular Stent Grafts for Abdominal Aortic Aneurysms

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Sign up for premerabluecrossofwashington Policy 7.01.601 alerts

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Policy Summary

PayerPremera Blue Cross of Washington

PolicyEndovascular Stent Grafts for Abdominal Aortic Aneurysms

Policy CodePolicy 7.01.601

Change TypeModified

Effective DateNovember 6, 2026

Last ReviewAug 18, 2026

Next Review DateNot specified

Key ActionSubmit office visit notes documenting the relevant history and physical examination, aneurysmal diameter, FDA-approved endoprosthesis, and at least one qualifying aneurysm condition.

SourceLink

POLICY UPDATE CHANGES

The policy added a statement addressing EVAR of infrarenal abdominal aortic or aorto-iliac aneurysms using endoprostheses when medical necessity criteria are met.

The policy added a statement that bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is investigational as treatment of abdominal aortic aneurysms.

The policy removed the criterion referring to an aneurysmal diameter measuring twice the size of the normal infrarenal aorta.

CPT code 34709 was added, and CPT codes 36200 and 36245 were deleted.

>5.0 cmMedical necessity threshold

0.5 cm/6 moGrowth criterion

≥3 cmAAA definition

2Investigational codes

12FDA-approved systems

Medical Necessity and Investigational Services

Medical Necessity Criteria for EVAR

EVAR of an infra-renal abdominal aortic or aorto-iliac aneurysm using an endoprosthesis is medically necessary when ALL of the following documentation and clinical criteria are met:

ALL of the following

Office visit notes document the relevant history and physical examination and the aneurysmal diameter.
The planned device is an FDA-approved endoprosthesis, including a standard, fenestrated, or branched device.
ONE or more of the following aneurysm criteria
- The aneurysmal diameter is greater than 5.0 cm.
- The aneurysmal diameter is 4.0 to 5.0 cm and has increased in size by 0.5 cm during the last six months.
- The patient has a ruptured abdominal aortic aneurysm (AAA).

Investigational Treatment

Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is considered investigational as a treatment of abdominal aortic aneurysms (AAAs).

AAA Eligible for Open Repair

EVAR may be considered as an alternative to open surgery when the patient is a candidate for both procedures.

ALL of the following

The patient has an abdominal aortic aneurysm eligible for open repair.
The patient is a candidate for both endovascular aneurysm repair and open surgical repair.

Ruptured AAA

For a ruptured AAA, EVAR is supported when the clinical and anatomic circumstances permit endovascular treatment.

ALL of the following

The patient has a ruptured abdominal aortic aneurysm requiring immediate repair.
The repair is clinically and anatomically appropriate
- The aneurysm has suitable anatomy for EVAR.
- The aneurysm is anatomically feasible for emergent EVAR.

Supporting evidence or guideline circumstance

Endovascular repair is recommended over open repair for ruptured AAA with suitable anatomy to reduce morbidity and mortality.

Nonruptured AAA With Suitable Anatomy or Elevated Operative Risk

For a nonruptured AAA, EVAR may be considered when the aneurysm meets repair criteria and the anatomy, operative risk, or patient-specific circumstances support endovascular treatment.

ALL of the following

The patient has a nonruptured abdominal aortic aneurysm that meets criteria for repair.
Repair criteria include a symptomatic AAA; an asymptomatic AAA larger than 4.0 cm that has grown by more than 1 cm in one year; or an asymptomatic AAA measuring 5.5 cm or larger.
ONE or more of the following endovascular circumstances applies
- The patient has low to moderate operative risk and suitable anatomy, and shared decision-making weighs the risks and benefits of EVAR versus open repair.
- The patient has high operative risk, and EVAR is reasonable to reduce 30-day morbidity, mortality, or both.

AAA Ineligible for Open Repair

For patients ineligible for open repair, evidence is insufficient to establish routine EVAR benefit. EVAR may be considered selectively when the clinical circumstances and anatomy support treatment.

ALL of the following

The patient has an abdominal aortic aneurysm and is ineligible or unfit for open repair because of prohibitive surgical risk, anaesthetic risk, medical comorbidities, or other factors.
Selected clinical circumstances support consideration of EVAR
- The patient is a high-risk patient unfit for surgical repair and has anatomy suitable for EVAR.
- The patient has a lower Gagne Index, a larger AAA diameter, and lacks frailty.
- Cardiopulmonary exercise testing identifies the patient as unfit for open repair and supports potential long-term survival benefit with EVAR relative to conservative management.

FDA-Approved Endoprostheses

Coverage may be considered when the applicable medical-necessity criteria are met.

The EVAR procedure uses an FDA-approved endoprosthesis, including a standard, fenestrated, or branched device.

Investigational Repair Configuration

Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is considered investigational.

Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is considered investigational as a treatment of AAAs.

This policy does not apply to Medicare Advantage.

Procedure and Product Coding

InvestigationalCPTExperimental

34717	Bifurcated-bifurcated aneurysm repair
34718	Bifurcated-bifurcated aneurysm repair

CPT coding - infrarenal and iliac endograft repairCPT

34701	Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft, including pre-procedure sizing and device selection, nonselective catheterization(s), associated radiological supervision and interpretation, endograft extension(s) from the renal arteries to the aortic bifurcation, and angioplasty/stenting from the renal arteries to the aortic bifurcation; for other than rupture.
34703	Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft, including pre-procedure sizing and device selection, nonselective catheterization(s), associated radiological supervision and interpretation, endograft extension(s) from the renal arteries to the iliac bifurcation, and angioplasty/stenting from the renal arteries to the iliac bifurcation; for other than rupture.
34704	Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft, including pre-procedure sizing and device selection, nonselective catheterization(s), associated radiological supervision and interpretation, endograft extension(s) from the renal arteries to the iliac bifurcation, and angioplasty/stenting from the renal arteries to the iliac bifurcation; for rupture, including temporary aortic and/or iliac balloon occlusion when performed.

CPT coding - extension prosthesesCPT

34709

Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, or penetrating ulcer, including pre-procedure sizing and device selection, nonselective catheterization(s), associated radiological supervision and interpretation, and treatment zone angioplasty/stenting when performed, per vessel treated.

34710

Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, nonselective catheterization(s), associated radiological supervision and interpretation, and treatment zone angioplasty/stenting when performed; initial vessel.

CPT coding - fenestrated visceral aortic endograftsCPT

34842	Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, including target zone angioplasty when performed, including two visceral artery endoprostheses.
34843	Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, including target zone angioplasty when performed, including three visceral artery endoprostheses.
34844	Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, including target zone angioplasty when performed, including four or more visceral artery endoprostheses.
34845	Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft and associated radiological supervision and interpretation, including target zone angioplasty when performed; including four or more visceral artery endoprostheses.
34846	Endovascular repair of visceral aorta and infrarenal abdominal aorta with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft, including one visceral artery endoprosthesis.
34847	Endovascular repair of visceral aorta and infrarenal abdominal aorta with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft, including two visceral artery endoprostheses.
34848	Endovascular repair of visceral aorta and infrarenal abdominal aorta with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft, including three visceral artery endoprostheses.

FDA Product Codemixed

MIH	FDA product code

Added CPT CodeCPT

34709

CPT code added in policy history; procedure description not provided in this window

Deleted CPT CodesCPT

36200	CPT code deleted in policy history; procedure description not provided in this window
36245	CPT code deleted in policy history; procedure description not provided in this window

Aneurysmal diameter

ThresholdGreater than 5.0 cm

MeasurementAneurysmal diameter

UseQualifying condition for EVAR medical necessity when required documentation is submitted

Aneurysmal diameter with interval growth

Diameter range4.0 to 5.0 cm

Interval growth

Documentation and Review Considerations

Documentation Required

Submit required EVAR documentation

For EVAR of infrarenal abdominal aortic or aorto-iliac aneurysms using endoprostheses, submit office visit notes containing the relevant history and physical examination and aneurysmal diameter. The record must also document an FDA-approved endoprosthesis—standard, fenestrated, or branched—and at least one qualifying aneurysm condition.

Aneurysmal diameter greater than 5.0 cm
Aneurysmal diameter of 4.0 to 5.0 cm with an increase of 0.5 cm during the last six months
Ruptured abdominal aortic aneurysm (AAA)

Denial Risk

Avoid investigational bifurcated-bifurcated repair

Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is considered investigational as a treatment of abdominal aortic aneurysms. Claims for this repair may be denied as investigational.

Clinical Background

An abdominal aortic aneurysm (AAA) is a weakened or enlarged portion of the abdominal aorta. As the aneurysm enlarges, the risk of rupture increases; rupture can cause life-threatening internal bleeding. Endovascular aneurysm repair (EVAR) uses a catheter to place a fabric-covered metal stent graft inside the affected aorta, creating a blood-flow channel and excluding the aneurysm from circulation. Compared with open surgery, EVAR generally involves smaller incisions and a shorter recovery period.

Terms and Repair Configurations

Abdominal aortic aneurysm

DefinitionBulge or enlargement of the lower part of the aorta

CauseWeakening of the artery wall

Anatomic descriptionThe aorta carries blood from the heart through the abdomen

Aorto-iliac aneurysm

Affected vesselsAbdominal aorta and/or iliac arteries

DefinitionBulge or enlargement of the affected vessels

CauseWeakened vessel walls

Policy Summary

PayerPremera Blue Cross of Washington

PolicyEndovascular Stent Grafts for Abdominal Aortic Aneurysms

Policy CodePolicy 7.01.601

Change TypeModified

Effective DateNovember 6, 2026

Last ReviewAug 18, 2026

Next Review DateNot specified

Key ActionSubmit office visit notes documenting the relevant history and physical examination, aneurysmal diameter, FDA-approved endoprosthesis, and at least one qualifying aneurysm condition.

SourceLink

On This Page

EVAR provides comparable short- and intermediate-term survival with reduced perioperative complications compared with open repair.

Emergent EVAR should be considered when anatomically feasible; immediate repair is recommended for a ruptured aneurysm.

The patient has moderate to high operative risk and suitable anatomy for an FDA-approved fenestrated endovascular device, making EVAR reasonable over open repair to reduce perioperative complications.

The patient has abdominal copathology, such as a hostile abdomen, horseshoe kidney, or a stoma, or other patient-specific considerations discussed with the patient that make EVAR the preferred option.

Anaesthetic risks or medical comorbidities contraindicate open surgical repair; EVAR or conservative management may be considered.

EVAR is not supported for routine use in patients ineligible for open repair: randomized trials comparing EVAR with no surgical intervention did not demonstrate superior outcomes, and the evidence is insufficient to determine improvement in net health outcome.

Consider EVAR only in selected patients after individualized assessment of operative risk, frailty, aneurysm size, anatomy, and expected benefit.

Increased by 0.5 cm during the last six months

UseQualifying condition for EVAR medical necessity when required documentation is submitted

Infrarenal abdominal aortic aneurysm

LocationAorta just below the kidneys

Minimum diameterGreater than or equal to 3 cm

DescriptionBulge or enlargement of the aorta

Asymptomatic AAA size

Aneurysm typeAsymptomatic abdominal aortic aneurysm

Repair consideration threshold5.5 cm or larger

Measurement methodInner-to-inner maximum anterior-posterior aortic diameter on ultrasound

AAA growth

Aneurysm sizeLarger than 4.0 cm

Growth thresholdMore than 1 cm in 1 year

Clinical useNICE criterion for considering repair of an asymptomatic AAA

Standard elective repair threshold

Standard threshold5.5 cm or larger in diameter

WomenSociety for Vascular Surgery guidance may recommend repair at 5.0 to 5.4 cm

Repair optionsOpen repair or EVAR

Asymptomatic AAA repair threshold

Aneurysm typeAsymptomatic abdominal aortic aneurysm

Repair threshold5.5 cm or larger

Measurement methodInner-to-inner maximum anterior-posterior aortic diameter on ultrasound

Rapid AAA growth threshold

Aneurysm sizeLarger than 4.0 cm

Rapid-growth thresholdMore than 1 cm in 1 year

Guideline contextNICE criterion for considering repair of an asymptomatic AAA

CPT 34717 and 34718 are identified for bifurcated-bifurcated aneurysm repair.

Bifurcated aneurysm repair

ProcedureA prosthetic graft is placed across the abdominal aorta

PurposeReplace a weakened or enlarged section

Graft configurationTwo branches connect to the iliac arteries to restore normal blood flow and prevent rupture

Bifurcated-bifurcated aneurysm repair

TechniqueEndovascular treatment of selected aorto-iliac aneurysms

ConfigurationA second bifurcated stent-graft configuration

PurposePreserve blood flow to the internal iliac artery while excluding aneurysmal segments

Branched endoprosthesis

DeviceStent-graft with multiple internal branches

PurposeMaintain blood flow to vital organs

Treatment roleBypass an abdominal aortic aneurysm

Fenestrated endoprosthesis

DeviceCustom-made stent-graft

DesignSmall, precisely placed openings called fenestrations

PurposePreserve blood flow to vital branch arteries, including the kidneys and intestines, while sealing the aneurysm

Infrarenal abdominal aortic aneurysm

LocationAorta just below the kidneys

Minimum diameterGreater than or equal to 3 cm

DefinitionBulge or enlargement in the aorta

Standard endoprosthesis

DeviceEndovascular stent-graft

IndicationTreatment of infrarenal abdominal aortic aneurysms

Anatomic requirementAnatomy must be suitable for a standard device configuration

Endoleak

DefinitionA perivascular leak associated with an endoprosthesis

Possible causesIncompetent graft seal, blood flow through aneurysm tributaries, or perforation of graft fabric

Clinical significanceMay contribute to aneurysm expansion

Endovascular aneurysm repair (EVAR)

Procedure typeCatheter-based repair

Treatment methodAn endovascular prosthesis is deployed across an abdominal aortic aneurysm

PurposeExclude the aneurysm from the circulation and restore normal blood flow

Straight graft

Device typeEndovascular graft

Proximal anchorAnchored to the infrarenal aorta

Distal anchorBoth ends are anchored to the infrarenal aorta

Bifurcated graft

Device typeEndovascular graft

Proximal anchorAnchored to the infrarenal aorta

Distal anchorsDistal ends are anchored to the iliac arteries

Fenestrated graft

DesignGraft with openings in the wall

Vessel preservationOpenings can be positioned across the renal or celiac arteries while preserving vessel patency

ExtensionsMay connect the main endograft body to visceral arteries to create a hemostatic seal