ModifiedPremera Blue Cross of WashingtonPolicy 7.01.601

Endovascular Stent Grafts for Abdominal Aortic Aneurysms

Customize your policy alerts

Sign up for premerabluecrossofwashington Policy 7.01.601 alerts

Get alerted when Policy 7.01.601 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs when endovascular aneurysm repair using endoprostheses for infrarenal abdominal aortic or aorto-iliac aneurysms may be medically necessary and what documentation is required. It also identifies bifurcated-bifurcated endoprosthesis repair as investigational.

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

Next Review DateN/A

Key ActionSubmit medical records demonstrating the relevant history and physical, aneurysm diameter, FDA-approved device type, and at least one qualifying aneurysm indication.

SourceLink

POLICY UPDATE CHANGES

The policy added a statement that endovascular aneurysm repair of infrarenal abdominal aortic or aorto-iliac aneurysms using endoprostheses may be covered when medical necessity criteria are met.

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

The policy removed the prior policy statement using an aneurysmal diameter measuring twice the normal infrarenal aorta as a criterion.

The policy added CPT code 34709 and deleted CPT codes 36200 and 36245.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedPremera Blue Cross of WashingtonPolicy 7.01.601

Endovascular Stent Grafts for Abdominal Aortic Aneurysms

Customize your policy alerts

Sign up for premerabluecrossofwashington Policy 7.01.601 alerts

Get alerted when Policy 7.01.601 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

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

Next Review DateN/A

Key ActionSubmit medical records demonstrating the relevant history and physical, aneurysm diameter, FDA-approved device type, and at least one qualifying aneurysm indication.

SourceLink

POLICY UPDATE CHANGES

The policy added a statement that endovascular aneurysm repair of infrarenal abdominal aortic or aorto-iliac aneurysms using endoprostheses may be covered when medical necessity criteria are met.

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

The policy removed the prior policy statement using an aneurysmal diameter measuring twice the normal infrarenal aorta as a criterion.

The policy added CPT code 34709 and deleted CPT codes 36200 and 36245.

>5.0 cmAneurysm diameter criterion

0.5 cm/6 moGrowth criterion

3Qualifying clinical pathways

InvestigationalBifurcated-bifurcated repair

5.5 cmElective repair threshold

Medical Necessity and Investigational Services

EVAR Medical Necessity and Documentation

Documentation submitted for review must demonstrate that medical necessity criteria are met for EVAR of infrarenal abdominal aortic or aorto-iliac aneurysms using an endoprosthesis.

ALL of the following

Office visit notes include the relevant history and physical examination and document the aneurysmal diameter.
The procedure uses an FDA-approved endoprosthesis, including a standard, fenestrated, or branched device.
ONE or more of the following
- Aneurysmal diameter is greater than 5.0 cm.> 5.0 cm
- Aneurysmal diameter is 4.0 to 5.0 cm and has increased in size by 0.5 cm during the preceding six months.Increase of 0.5 cm in 6 months
- The patient has a ruptured abdominal aortic aneurysm (AAA).

Investigational Bifurcated-Bifurcated Repair

The following repair configuration is not covered as medically necessary under this policy.

Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms, including CPT codes 34717 and 34718, is considered investigational for treatment of abdominal aortic aneurysms.

AAA Eligible for Open Repair

For patients with an AAA eligible for open repair, EVAR may be considered when the patient is a candidate for both EVAR and open surgical repair.

ALL of the following

The patient has an abdominal aortic aneurysm eligible for open surgical repair.
The patient is also an appropriate candidate for EVAR, including suitable anatomy for the selected FDA-approved endoprosthesis.
The risks and benefits of EVAR versus open repair have been evaluated and discussed as part of shared decision-making.

Ruptured AAA With Suitable Anatomy

For a ruptured AAA with suitable anatomy, EVAR is recommended over open repair when an appropriate FDA-approved endoprosthesis can be used.

ALL of the following

The patient has a ruptured infrarenal abdominal aortic aneurysm.
The anatomy is suitable for EVAR with an appropriate FDA-approved endoprosthesis.
EVAR is selected to reduce the risk of perioperative morbidity and mortality; open repair remains an option when standard EVAR is unsuitable.

AAA Ineligible for Open Repair

Evidence is insufficient to establish that EVAR improves net health outcomes for patients with AAAs who are ineligible for open repair.

Evidence and coverage position

The patient is considered ineligible or unfit for open AAA repair because of prohibitive surgical risk or other factors.
Randomized trials comparing EVAR with no surgical intervention did not demonstrate superior outcomes in this population.
EVAR should not be considered established as medically necessary solely because the patient is ineligible for open repair; any potential benefit appears limited to selected patients and remains insufficiently established.

Unruptured AAA Treatment Threshold

For an unruptured AAA, consider repair when at least one of the following NICE criteria is met.

ONE or more of the following

The unruptured AAA is symptomatic.
The AAA is asymptomatic, larger than 4.0 cm, and has grown by more than 1 cm in one year, measured inner-to-inner maximum anterior-posterior aortic diameter on ultrasound.> 4.0 cm and growth > 1 cm in 1 year
The asymptomatic AAA is 5.5 cm or larger, measured inner-to-inner maximum anterior-posterior aortic diameter on ultrasound.≥ 5.5 cm

Endovascular Aneurysm Repair

Endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic or aorto-iliac aneurysm using an FDA-approved endoprosthesis is medically necessary when the applicable medical necessity and documentation criteria are met.

ALL applicable criteria

The EVAR procedure is performed for an infrarenal abdominal aortic or aorto-iliac aneurysm.
The device is an FDA-approved endoprosthesis.
The patient meets at least one qualifying aneurysm indication and the submitted records document medical necessity.

Investigational Repair Configuration

Coverage does not extend to repair configurations designated investigational by this policy.

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

Bifurcated-bifurcated aneurysm repair (CPT 34717 and 34718) is considered investigational.

The policy's updated coverage position remains that bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is investigational for treatment of abdominal aortic aneurysms.

Procedure, Device, and Coverage Coding

InvestigationalCPTExperimental

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

CPT coding - infrarenal aortic and aorto-uni-iliac endograft repairCPT

34701	Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of 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, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of 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, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of 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, penetrating ulcer, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated; listed separately in addition to the code for the primary procedure.

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, all nonselective catheterization(s), all 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 one visceral artery endoprosthesis.
34843	Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, including two visceral artery endoprostheses.
34844	Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, including three visceral artery endoprostheses.
34845	Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, 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

FDA Premarket Approval Identifiersmixed

P990020	AneuRx Prosthesis System (AneuRx AAAdvantage Stent Graft)
P990017	Ancure Aortoiliac System
P020004	Gore Excluder
P020018	Zenith AAA Endovascular Graft
P040002	Endologix Powerlink (Afx Endovascular AAA system)
P070027	Talent Abdominal Stent Graft System
P100021	Endurant II AAA Stent Graft System
P120006	Ovation Abdominal Stent Graft System and Alto Abdominal Stent Graft System
P110032	Aorfix AAA Flexible Stent Graft System
P150002	Incraft AAA Stent Graft System

1–10 of 11

1/2

Policy Coding ChangesCPT

34709	CPT code added in the policy update
36200	CPT code deleted in the policy update
36245	CPT code deleted in the policy update

Aneurysmal diameter

Aneurysmal diameter> 5.0 cm

Applicable procedureEndovascular aneurysm repair using an endoprosthesis

DocumentationRecord the aneurysmal diameter in the submitted medical records

Aneurysmal diameter with documented growth

Aneurysmal diameter4.0 to 5.0 cm

Required growth

Documentation and Submission Requirements

Prior Authorization

Submit medical-necessity records

For review of EVAR for an infrarenal abdominal aortic or aorto-iliac aneurysm using an endoprosthesis, submit medical records demonstrating that medical necessity criteria are met.

Include the relevant history and physical examination.
Include the aneurysm diameter and FDA-approved device type.
Document at least one qualifying aneurysm indication.

Documentation Required

Document EVAR medical necessity

Submit office visit notes containing the relevant history and physical examination and the aneurysmal diameter. Documentation must identify use of an FDA-approved endoprosthesis, including a standard, fenestrated, or branched device, and document at least one qualifying clinical indication.

Clinical Background

An abdominal aortic aneurysm (AAA) is a weakened, enlarged segment of the aorta that can rupture and cause life-threatening bleeding. Endovascular aneurysm repair (EVAR) places a fabric-covered metal stent graft inside the aorta through catheter access to exclude the aneurysm from circulation, providing a minimally invasive alternative to open repair. This policy addresses EVAR for infrarenal abdominal aortic and aorto-iliac aneurysms using standard, fenestrated, or branched endoprostheses.

Terms and Abbreviations

Abdominal aortic aneurysm

DefinitionA bulge or enlargement of the lower part of the aorta caused by weakening of the artery wall

Anatomic locationThe lower part of the aorta that carries blood from the heart through the abdomen

AbbreviationAAA

Aorto-iliac aneurysm

DefinitionA bulge or enlargement of the abdominal aorta and/or iliac arteries due to weakened vessel walls

Vessels involvedThe abdominal aorta and/or iliac arteries

Underlying feature

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

Next Review DateN/A

Key ActionSubmit medical records demonstrating the relevant history and physical, aneurysm diameter, FDA-approved device type, and at least one qualifying aneurysm indication.

SourceLink

On This Page

Increased by 0.5 cm in the last six months

DocumentationRecord the aneurysm diameter and documented interval growth

Rupture

Qualifying conditionRuptured abdominal aortic aneurysm

AbbreviationAAA

DocumentationThe medical record should document the rupture

Rapid AAA growth

AAA statusAsymptomatic and unruptured

Minimum diameterLarger than 4.0 cm

Required growthMore than 1 cm in 1 year

AAA diameter for repair consideration

Standard repair considerationAAA diameter 5.5 cm or larger

Women’s guidanceSociety for Vascular Surgery guidance cited by USPSTF recommends considering repair at 5.0 to 5.4 cm in women

Measurement contextThe cited standard applies to elective surgical referral or intervention

Standard elective repair threshold

Elective repair thresholdAAA diameter at least 5.5 cm

Repair optionsOpen repair or EVAR

Referral contextPatients meeting the threshold should be referred for surgical intervention

Society for Vascular Surgery threshold cited for women

PopulationWomen with an abdominal aortic aneurysm

Diameter range5.0 to 5.4 cm

Guidance sourceSociety for Vascular Surgery guidance cited by the USPSTF

Aneurysmal diameter greater than 5.0 cm.

Aneurysmal diameter of 4.0 to 5.0 cm with growth of 0.5 cm during the preceding six months.

Ruptured abdominal aortic aneurysm.

Denial Risk

Flag bifurcated-bifurcated repair as investigational

Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is considered investigational as a treatment of abdominal aortic aneurysms. Do not submit this configuration as a covered EVAR treatment without recognizing its investigational status.

Applicable CPT codes: 34717 and 34718.

Denial Risk

Review the repair configuration before submission

Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is considered investigational for treatment of abdominal aortic aneurysms. This repair configuration may therefore be denied under the policy’s investigational coverage position.

Weakening of the vessel walls

Infra-renal abdominal aortic aneurysm

DefinitionA bulge or enlargement in the aorta just below the kidneys

Diameter thresholdGreater than or equal to 3 cm

Clinical descriptionThe most common type of abdominal aortic aneurysm

Branched endoprosthesis

DefinitionAn endovascular stent-graft with multiple internal branches

PurposeMaintains blood flow to vital organs while bypassing an abdominal aortic aneurysm

Device typeEndoprosthesis used in endovascular aneurysm treatment

Fenestrated endoprosthesis

DefinitionA custom-made stent-graft with small, precisely placed openings called fenestrations

PurposeAllows blood flow to vital branch arteries, including the kidneys and intestines, while sealing off an abdominal aortic aneurysm

Typical useUsed when a standard stent would block branch vessels, typically for complex aneurysms near major branch arteries

Standard endoprosthesis

DefinitionAn endovascular stent-graft used to treat infrarenal abdominal aortic aneurysms

Use conditionUsed when the anatomy is suitable for a standard device configuration

Anatomic targetInfrarenal abdominal aortic aneurysms

Bifurcated-bifurcated aneurysm repair

DefinitionAn endovascular technique for selected aorto-iliac aneurysms

ConfigurationUses a second bifurcated stent-graft configuration

PurposePreserves blood flow to the internal iliac artery while excluding aneurysmal segments of the abdominal aorta and iliac arteries

Endoleak

DefinitionA perivascular leak involving blood flow into the aneurysm sac after endovascular graft placement

Potential causesAn incompetent graft seal, flow through aneurysm tributaries, or graft fabric perforation

Clinical significanceA post-EVAR complication that may result in aneurysm expansion

Straight graft

DefinitionAn endovascular graft in which both ends are anchored to the infrarenal aorta

Proximal anchorInfrarenal aorta

Distal anchorInfrarenal aorta

Bifurcated graft

DefinitionAn endovascular graft with a proximal end anchored to the infrarenal aorta and distal ends anchored to the iliac arteries

Proximal anchorInfrarenal aorta

Distal anchorsIliac arteries

Fenestrated graft

DefinitionA graft designed with openings in its wall

PositioningOpenings can be positioned across the renal or celiac arteries

PurposeMaintains patency of those critical vessels while protecting the aneurysm

EVAR

AbbreviationEVAR

Expanded termEndovascular aneurysm repair

TechniqueUses an endovascular stent graft to exclude an abdominal aortic aneurysm from circulation

AAA

AbbreviationAAA

Expanded termAbdominal aortic aneurysm

Clinical subjectAn aneurysm of the abdominal aorta addressed by open repair or EVAR

EVAR

AbbreviationEVAR

Expanded termEndovascular aneurysm repair

Policy contextRepair of infrarenal abdominal aortic or aorto-iliac aneurysms using endoprostheses

FDA

AbbreviationFDA

Expanded termFood and Drug Administration

Policy contextThe FDA approves abdominal aortic stent grafts through the premarket approval process

PMA

AbbreviationPMA

Expanded termPremarket approval

Regulatory contextThe PMA process is used for FDA approval of abdominal aortic stent grafts