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    OpenPayerPolicy UpdatesVascular/Cardiothoracic SurgeryPremera WA EVAR AAA Coverage Update | OpenPayer
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    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 may be medically necessary for infrarenal abdominal aortic or aorto-iliac aneurysms, including standard, fenestrated, and branched devices. It also identifies an investigational bifurcated-bifurcated repair and specifies documentation and coding information for providers.

    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 ActionDocument 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 coverage statement for endovascular aneurysm repair 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 for treatment of abdominal aortic aneurysms.

    The policy removed the prior policy statement requiring an aneurysmal diameter twice the size of the normal infrarenal aorta.

    CPT code 34709 was added, and CPT codes 36200 and 36245 were deleted from the policy coding information.

    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.

    >5.0 cmRepair diameter criterion
    0.5 cm/6 moGrowth criterion
    34717, 34718Investigational codes
    3 cmAAA definition threshold
    13FDA-approved systems

    Medical Necessity and Coverage Criteria

    EVAR Medical Necessity

    Medical necessity documentation should establish all of the following.

    EVAR medical necessity

    • Qualifying aneurysm condition

      • Large aneurysm: Aneurysmal diameter is greater than 5.0 cm.>5.0 cm
      • Interval enlargement: Aneurysmal diameter is 4.0 to 5.0 cm and has increased in size by 0.5 cm in the last six months.4.0-5.0 cm; growth of 0.5 cm within six months
      • Rupture: The abdominal aortic aneurysm is ruptured.

    Investigational Bifurcated-Bifurcated Repair

    The procedure is considered investigational.

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

    Nonruptured AAA

    ACC/AHA recommendations for nonruptured AAA

    Nonruptured AAA clinical scenarios: Endovascular repair may be selected through shared decision-making for patients with nonruptured AAA, low to moderate operative risk, suitable anatomy, and consideration of risks and benefits; it is reasonable for patients with high operative risk to reduce 30-day morbidity or mortality; and it is reasonable over open repair for patients with moderate to high operative risk and suitable anatomy for an FDA-approved fenestrated device.Suitable anatomy and operative-risk assessment

    Guideline recommendation, not stated payer coverage criteria.

    Ruptured AAA

    ACC/AHA recommendation for ruptured AAA

    Ruptured AAA: Endovascular repair is recommended over open repair when the ruptured AAA has suitable anatomy, to reduce morbidity and mortality.Suitable anatomy

    Guideline recommendation, not stated payer coverage criteria.

    Unruptured AAA Repair Thresholds

    NICE indications for considering repair of an unruptured AAA

    Unruptured AAA repair indications: Consider repair when the AAA is symptomatic; when asymptomatic, larger than 4.0 cm and has grown by more than 1 cm in 1 year; or when asymptomatic and 5.5 cm or larger.Symptomatic; or >4.0 cm with >1 cm growth in 1 year; or ≥5.5 cm

    NICE recommendation; the document does not present this as a payer coverage rule.

    EVAR Selection for Unruptured AAA

    NICE situations favoring or permitting EVAR

    EVAR selection factors: Consider EVAR for an eligible unruptured AAA when abdominal copathology or other patient-specific considerations may make EVAR preferable, or consider EVAR or conservative management when anesthetic risks or medical comorbidities contraindicate open repair.Meets repair criteria and has relevant anatomy, copathology, anesthetic risk, or comorbidity

    NICE recommendation; evidence in patients ineligible for open repair is described elsewhere as insufficient for a definitive net-health-outcome conclusion.

    Ruptured AAA Repair

    NICE recommendations for ruptured infrarenal AAA

    Ruptured infrarenal AAA: Consider EVAR or open surgical repair for a ruptured infrarenal AAA; consider open repair if standard EVAR is unsuitable.Ruptured infrarenal AAA; standard EVAR suitability

    NICE recommendation; the document does not present this as a payer coverage rule.

    FDA-Approved Endoprosthesis Repair

    Medical necessity statement

    FDA-approved endoprosthesis and medical-necessity criteria: Use of endoprostheses approved by the FDA for treatment of abdominal aortic aneurysms may be considered medically necessary when the policy's medical-necessity criteria are met.

    The detailed criteria are not present in this document window.

    Investigational Aorto-Iliac Aneurysm Repair

    Investigational policy statement

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

    Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is considered investigational as treatment of abdominal aortic aneurysms. The policy does not establish this approach as medically necessary coverage.

    Coding and Policy Thresholds

    InvestigationalCPTExperimental
    34717Bifurcated-bifurcated aneurysm repair
    34718Bifurcated-bifurcated aneurysm repair
    CPT codesCPT
    34701Endovascular 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.
    34703Endovascular 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.
    34704Endovascular 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 codesCPT
    34709Placement 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, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated.
    34710Delayed 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 codesCPT
    34842Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, including one visceral artery endoprosthesis.
    34843Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, including two visceral artery endoprostheses.
    34844Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, including three visceral artery endoprostheses.
    CPT codesCPT
    34845Endovascular repair of visceral aorta by deployment of a fenestrated visceral aortic endograft, including four or more visceral artery endoprostheses.
    34846Endovascular 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.
    34847Endovascular 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.
    34848Endovascular 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.
    Added CPT codeCPT
    34709CPT code added; description not provided in this window
    Deleted CPT codesCPT
    36200CPT code deleted; description not provided in this window
    36245CPT code deleted; description not provided in this window
    FDA product codeHCPCS
    MIHFDA product code for endovascular abdominal aortic grafts
    Aneurysmal Diameter
    Aneurysmal diameterGreater than 5.0 cm
    Applies toEndovascular aneurysm repair of infrarenal abdominal aortic or aorto-iliac aneurysms
    Qualifying statusOne qualifying aneurysm condition supporting medical necessity
    Aneurysmal Diameter With Interval Growth
    Aneurysmal diameter4.0 to 5.0 cm

    Documentation and Provider Actions

    Documentation Required

    Document history, physical examination, and aneurysm measurement

    Submit office visit notes containing the relevant history and physical examination and the aneurysmal diameter.

    Documentation Required

    Document the FDA-approved endoprosthesis

    Document use of an FDA-approved endoprosthesis for the EVAR procedure, including a standard, fenestrated, or branched device.

    Documentation Required

    Document a qualifying aneurysm condition

    Document at least one qualifying aneurysm condition: an aneurysmal diameter greater than 5.0 cm; an aneurysmal diameter of 4.0 to 5.0 cm that has increased in size by 0.5 cm in the last six months; or a ruptured abdominal aortic aneurysm.

    Clinical Background

    An abdominal aortic aneurysm (AAA) is a weakened or enlarged portion of the abdominal aorta that may rupture and cause life-threatening bleeding. An aorto-iliac aneurysm may involve the abdominal aorta and/or iliac arteries. An infrarenal AAA is located below the kidneys and measures at least 3 cm in diameter.

    Endovascular aneurysm repair (EVAR) excludes the aneurysm from circulation by placing a fabric-covered metal stent graft through catheter access, restoring blood flow while generally avoiding the larger incisions required for open repair. This policy addresses medical necessity for EVAR of infrarenal abdominal aortic and aorto-iliac aneurysms using FDA-approved standard, fenestrated, or branched endoprostheses.

    Definitions and Terminology

    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, the main artery carrying blood from the heart through the abdomen.
    Clinical concernThe weakened or enlarged section may require repair to restore blood flow and prevent rupture.
    Aorto-Iliac Aneurysm
    DefinitionA bulge or enlargement of the abdominal aorta and/or iliac arteries due to weakened vessel walls.
    Vessels involvedThe abdominal aorta, the iliac arteries, or both.
    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 ActionDocument the relevant history and physical examination, aneurysmal diameter, FDA-approved endoprosthesis, and at least one qualifying aneurysm condition.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaCoding and Policy ThresholdsDocumentation and Provider ActionsClinical BackgroundDefinitions and Terminology
    Interval growth
    Increased in size by 0.5 cm within the last six months
    Qualifying statusOne qualifying aneurysm condition supporting medical necessity
    Asymptomatic Unruptured AAA Repair Consideration
    Aneurysm statusAsymptomatic and unruptured abdominal aortic aneurysm
    Repair consideration threshold5.5 cm or larger
    Measurement methodInner-to-inner maximum anterior-posterior aortic diameter on ultrasound
    Rapidly Enlarging Asymptomatic Unruptured AAA
    Aneurysm statusAsymptomatic and unruptured abdominal aortic aneurysm
    Size thresholdLarger than 4.0 cm
    Annual growth thresholdGrown by more than 1 cm in one year
    Standard Elective AAA Repair Threshold
    Standard elective repair thresholdAAA diameter of 5.5 cm or larger
    WomenSociety for Vascular Surgery guidance may recommend repair at 5.0 to 5.4 cm
    Repair optionsOpen repair or endovascular aneurysm repair
  1. >5.0 cm aneurysmal diameter
  2. 4.0–5.0 cm aneurysmal diameter with 0.5 cm growth in the last six months
  3. Ruptured abdominal aortic aneurysm
    4. 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. This approach may result in an investigational or noncovered determination.

    • CPT 34717 and 34718 are identified with this investigational repair.
    Denial Risk

    Incomplete records may fail medical necessity review

    Records that do not document the relevant history and physical, aneurysmal diameter, use of an FDA-approved endoprosthesis, and at least one qualifying aneurysm condition may fail medical necessity review.

    • Include the office visit history and physical examination.
    • Include the aneurysmal diameter.
    • Identify the FDA-approved device as standard, fenestrated, or branched.
    • Document at least one qualifying aneurysm condition.
    Denial Risk

    Aorto-iliac bifurcated-bifurcated repair is investigational

    Bifurcated-bifurcated endoprosthesis repair of aorto-iliac aneurysms is considered investigational as treatment of abdominal aortic aneurysms. Providers should recognize that use of this repair approach may support an investigational or noncovered determination.

    Underlying change
    Weakening of the vessel walls.
    Bifurcated Aneurysm Repair
    DefinitionA surgical procedure in which a prosthetic graft is placed across the abdominal aorta to replace a weakened or enlarged section.
    Graft configurationThe graft has two branches.
    Branch connectionsThe two branches connect to the iliac arteries to restore normal blood flow and prevent rupture.
    Bifurcated-Bifurcated Aneurysm Repair
    DefinitionAn endovascular technique for selected aorto-iliac aneurysms using a second bifurcated stent-graft configuration.
    Flow preservationThe configuration preserves blood flow to the internal iliac artery.
    Treatment objectiveIt excludes aneurysmal segments of the abdominal aorta and iliac arteries.
    Branched Endoprosthesis
    DefinitionA stent-graft with multiple internal branches designed to maintain blood flow to vital organs while bypassing an abdominal aortic aneurysm.
    Device structureMultiple internal branches are incorporated into the stent-graft.
    Treatment functionThe device bypasses the aneurysm while maintaining blood flow to vital organs.
    Fenestrated Endoprosthesis
    DefinitionA custom-made stent-graft with small, precisely placed openings called fenestrations.
    Branch-vessel flowThe openings allow blood to continue flowing to vital branch arteries, including the renal and intestinal arteries.
    Treatment functionThe graft seals off an abdominal aortic aneurysm and may be used when a standard stent would block these vessels.
    Infrarenal Abdominal Aortic Aneurysm
    DefinitionA bulge or enlargement in the aorta just below the kidneys.
    Diameter thresholdGreater than or equal to 3 cm in diameter.
    Anatomic locationThe infrarenal segment of the aorta.
    Standard Endoprosthesis
    DefinitionAn endovascular stent-graft used to treat infrarenal abdominal aortic aneurysms.
    Anatomic useUsed for infrarenal abdominal aortic aneurysms.
    SuitabilityUsed when anatomy is suitable for a standard device configuration.
    Endovascular Aneurysm Repair (EVAR)
    DefinitionAneurysm exclusion from the circulation using an endovascular prosthesis.
    ApproachAn endovascular, catheter-based treatment using a prosthesis.
    Treatment resultNormal blood flow is restored after the aneurysm is excluded from circulation.
    Endoleak
    DefinitionPerivascular leakage around an endoprosthesis.
    Possible causeAn incompetent seal at a graft attachment site.
    Other causesBlood flow from aneurysm tributaries or perforation of the graft fabric.
    Bifurcated Graft
    DefinitionA graft with a proximal end anchored in the infrarenal aorta and distal ends anchored in the iliac arteries.
    Proximal anchoringThe proximal end is anchored in the infrarenal aorta.
    Distal anchoringThe distal ends are anchored in the iliac arteries.
    Fenestrated Graft
    DefinitionA graft designed with openings that can be positioned across the renal or celiac arteries.
    Vessel preservationThe openings maintain patency of the renal or celiac arteries.
    Device purposeThe graft protects the aneurysm while preserving flow through critical branch arteries.
    FDA
    AbbreviationFDA
    MeaningFood and Drug Administration
    Policy contextThe FDA approves abdominal aortic stent grafts through the premarket approval process.
    PMA
    AbbreviationPMA
    MeaningPremarket approval
    Policy contextThe PMA process is used for FDA approval of endovascular grafts for abdominal aortic aneurysms.