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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyPriority Health Medicare IVL Coverage | OpenPayer
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    CurrentPriority Health MedicarePolicy 91639

    Intravascular Lithotripsy

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    This policy governs coverage of intravascular lithotripsy for endovascular revascularization of lower-extremity and coronary arteries. Lower-extremity use is medically necessary only when specified lesion, runoff, calcium, and vessel criteria are met; coronary use is experimental and investigational.

    Policy Summary
    PayerPriority Health Medicare
    PolicyIntravascular Lithotripsy
    Policy CodePolicy N/A
    Change TypeAdministrative updateno material clinical or coverage change
    Effective Date09/01/2026
    Next Review DateN/A
    Key ActionWhen prior authorization is required, submit a medical-necessity request and obtain prior plan approval for investigational or unproven treatment.
    SourceLink
    POLICY UPDATE CHANGES

    The policy changes were limited to formatting, updated background, and updated references.

    2Vascular applications addressed
    ≥70%Required target-lesion stenosis
    7Lower-extremity exclusion conditions

    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.

    14Studies in cited 2026 peripheral IVL review
    17References listed
    4Past committee review dates

    Medical Necessity and Coverage Criteria

    Lower-extremity endovascular revascularization

    Covered as medically necessary when all of the following criteria are met.

    Lower-extremity IVL medical necessity

    • Native lesion: The target lesion is located in a native, de novo artery.

    • Stenosis and lesion length

      • Target-lesion stenosis: The target lesion is at least 70% stenosed by visual estimate.≥70% stenosis

      • Applicable lesion-length pathway

        • 70–99% stenosis pathway: The target lesion is 70–99% stenosed and its length is no more than 180 mm.≤180 mm
        • Chronic total occlusion pathway: The target lesion is a chronic total occlusion and its length is at least 20 mm.≥20 mm
    • Tibial-vessel runoff: The member has at least one patent tibial vessel in the target leg with runoff to the foot.No stenosis >50%
    • Calcification: The target lesion is calcified.

    Lower-extremity exclusions

    Not medically necessary if any one of the following conditions is present.

    Lower-extremity exclusion criteria

    • The target lesion is below the knee.
    • In-stent restenosis is within 10 mm of the target zone.
    • The lesion is within 10 mm of the ostium of the superficial femoral artery (SFA) or within 10 mm of the ostium of the anterior tibial artery.
    • There is evidence of an aneurysm or thrombus in the target vessel.
    • There is no calcium in the target lesion.

    Coronary IVL: experimental and investigational

    Coronary intravascular lithotripsy is not covered under the policy's medical-necessity stance.

    Coronary IVL: Intravascular lithotripsy for endovascular revascularization of the coronary arteries is experimental and investigational due to insufficient evidence of effectiveness in improving clinical outcomes.

    Lower-extremity intravascular lithotripsy is not medically necessary when the target lesion is below the knee.

    Lower-extremity intravascular lithotripsy is not medically necessary for in-stent restenosis within 10 mm of the target zone.

    Lower-extremity intravascular lithotripsy is not medically necessary when the lesion is within 10 mm of the ostium of the superficial femoral artery (SFA) or within 10 mm of the ostium of the anterior tibial artery.

    Lower-extremity intravascular lithotripsy is not medically necessary when there is evidence of an aneurysm or thrombus in the target vessel.

    Lower-extremity intravascular lithotripsy is not medically necessary when the target lesion has no calcium. The covered use requires a calcified lesion.

    Lower-extremity intravascular lithotripsy is not medically necessary when the target lesion is within a native or synthetic vessel graft.

    Lower-extremity intravascular lithotripsy is not medically necessary when the guidewire cannot be successfully crossed across the target lesion. Successful crossing requires the guidewire tip to be distal to the target lesion without flow-limiting dissections or perforations.

    Coronary intravascular lithotripsy for endovascular coronary revascularization is experimental and investigational because there is insufficient evidence of effectiveness in improving clinical outcomes.

    Coding and Thresholds

    Covered CPT CodesCPTCovered
    C9764Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed
    C9765Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed
    C9766Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed
    C9767Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed
    37262Intravascular lithotripsy(ies), iliac vascular territory, including all imaging guidance and radiological supervision and interpretation necessary to perform the intravascular lithotripsy(ies) within the same artery (List separately in addition to code for primary procedure)
    37279Intravascular lithotripsy(ies), femoral and popliteal vascular territory, including all imaging guidance and radiological supervision and interpretation necessary to perform the intravascular lithotripsy(ies) within the same artery (List separately in addition to code for primary procedure)
    Tibial/peroneal artery(ies)CPT
    C9772Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed
    C9773Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed
    C9774Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed
    C9775Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed
    Coronary artery(ies): Not Medically NecessaryCPTNot Covered
    C1761Catheter, transluminal intravascular lithotripsy, coronary
    92972Percutaneous transluminal coronary lithotripsy (List separately in addition to code for primary procedure)
    Target-lesion stenosis
    Qualifying stenosisAt least 70% stenosis
    Assessment methodBy visual estimate
    Applicable lesionTarget lesion for lower-extremity endovascular revascularization
    70–99% stenosed lesion length
    Stenosis range70% to 99% stenosed
    Maximum lesion length180 mm or less
    Applicable pathway

    Authorization and Documentation Requirements

    Prior Authorization

    Authorization Depends on Plan Requirements

    Prior authorization requirements depend on the member’s plan. When prior authorization is required, providers must submit a request demonstrating that the drug, service, or procedure is medically necessary. Check Priority Health Prism under Authorizations → Authorization Criteria Lookup for applicable EviCore, InterQual, or TurningPoint guidelines, or consult the Priority Health Provider Manual.

    Documentation Required

    Medical-Necessity and Exception Requests

    Requests for individual consideration of investigational yet promising treatment require prior plan approval. The provider must submit a request demonstrating medical necessity; coverage determinations for experimental, investigational, or unproven treatment are made by a Priority Health medical director or clinical pharmacist.

    • An exception review may be requested when the condition is a terminal illness or a chronic, life-threatening, severely disabling disease causing serious clinical deterioration.

    Clinical Background

    Intravascular lithotripsy combines ultrasound mechanical pulse waves with balloon angioplasty to treat stenotic or occluded peripheral arteries. The pulse waves disrupt calcified plaque within the vessel, while the balloon helps dilate the treated segment.

    Operational Definitions

    Successful guidewire crossing
    Guidewire positionThe guidewire tip is distal to the target lesion
    Dissection requirementNo flow-limiting dissections
    Perforation requirementNo flow-limiting perforations
    Patent tibial vessel with runoff to the foot
    Patent vessel requirementAt least one tibial vessel in the target leg is patent to the foot
    Runoff definitionRunoff to the foot
    Stenosis limitNo stenosis greater than 50%
    Policy Summary
    PayerPriority Health Medicare
    PolicyIntravascular Lithotripsy
    Policy CodePolicy N/A
    Change TypeAdministrative updateno material clinical or coverage change
    Effective Date09/01/2026
    Next Review DateN/A
    Key ActionWhen prior authorization is required, submit a medical-necessity request and obtain prior plan approval for investigational or unproven treatment.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaCoding and ThresholdsAuthorization and Documentation RequirementsClinical BackgroundOperational Definitions
    The target lesion is within a native or synthetic vessel graft.
  1. The guidewire cannot be successfully crossed across the target lesion.

    Successful crossing requires the guidewire tip to be distal to the target lesion without flow-limiting dissections or perforations.

    2. 70–99% stenosed target lesion
    Chronic total occlusion lesion length
    Lesion typeChronic total occlusion
    Minimum lesion lengthAt least 20 mm
    Applicable pathwayChronic total occlusion target lesion
    Tibial-vessel runoff stenosis
    Runoff requirementAt least one patent tibial vessel on the target leg with runoff to the foot
    Maximum stenosisNo stenosis greater than 50%
    Applicable vesselTibial vessel on the target leg
    Denial Risk

    Lower-Extremity Denial-Risk Conditions

    Lower-extremity intravascular lithotripsy is not medically necessary when any listed exclusion or technical failure condition is present.

    • Target lesion is below the knee.
    • In-stent restenosis is within 10 mm of the target zone.
    • Lesion is within 10 mm of the ostium of the superficial femoral artery (SFA) or anterior tibial artery.
    • Aneurysm or thrombus is present in the target vessel.
    • Target lesion has no calcium.
    • Target lesion is within a native or synthetic vessel graft.
    • The guidewire cannot successfully cross the target lesion; successful crossing requires the guidewire tip to be distal to the lesion without flow-limiting dissection or perforation.
    Denial Risk

    Coronary IVL Is Not Medically Necessary

    Coronary-artery intravascular lithotripsy is considered experimental and investigational and not medically necessary because evidence is insufficient to demonstrate effectiveness in improving clinical outcomes.

    • Coronary lithotripsy codes identified in the policy include C1761 and 92972; both are categorized as not medically necessary for coronary use.
    Note

    Benefit and Plan-Document Limitations

    Coverage remains subject to the member’s specific benefits and applicable plan documents. Group-specific policy, self-funded plan documents, individual policy documents, or state-mandated benefits may supersede or govern over this policy when they conflict; for Medicare members, CMS coverage determinations control when adopted.

    • HMO/EPO, POS, and PPO: verify the applicable insured plan and individual plan documents.
    • ASO/self-funded plans: consult the individual plan documents.
    • Individual policies: the individual insurance policy governs if there is a conflict.
    • Medicare: coverage is determined by CMS; if CMS has not adopted a coverage determination, this policy applies.
    • Medicaid/Healthy Michigan Plan: verify the Michigan Medicaid Fee Schedule and applicable Michigan Medicaid Provider Manual and contract requirements.