CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Peripheral Vascular Stents

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Coverage and medical-necessity criteria for peripheral arterial, venous, renal, and related vascular stent procedures, including experimental or investigational uses and product-specific limitations.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyPeripheral Vascular Stents

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionDocument the indication, vascular location, treatment type, symptoms, ischemic complications, and clinical result of balloon dilation when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NonePrior authorization

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CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Peripheral Vascular Stents

Customize your policy alerts

Sign up for all security_health_plan_of_wisconsin_inc policy alerts

Know when security_health_plan_of_wisconsin_inc releases new policies or updates existing guidance.

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Coverage and medical-necessity criteria for peripheral arterial, venous, renal, and related vascular stent procedures, including experimental or investigational uses and product-specific limitations.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyPeripheral Vascular Stents

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionDocument the indication, vascular location, treatment type, symptoms, ischemic complications, and clinical result of balloon dilation when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NonePrior authorization

Covered peripheral arterial indications

10Renal artery stenting criteria

ExperimentalUnsupported uses

2017-06-01Original effective date

2026-06-01Current effective date

Medical Necessity and Coverage Criteria

FDA-approved peripheral arterial stenting

FDA-approved peripheral artery stenting is medically necessary when at least one listed indication is met.

Covered primary or salvage peripheral arterial stenting indications

Primary therapy for common iliac artery stenosis or occlusion; external iliac artery stenosis or occlusion; chronic mesenteric ischemia; symptomatic posterior cerebral or cerebellar ischemia caused by subclavian artery stenosis in a person at high risk of surgical complications; symptomatic extremity ischemia caused by subclavian artery stenosis following percutaneous transluminal angioplasty; or femoropopliteal artery disease when treated with the Zilver PTX drug-eluting peripheral stent.
Salvage therapy for brachiocephalic arteries in subclavian steal syndrome, upper-extremity claudication, arm or hand ischemic rest pain, nonhealing tissue ulceration, or focal gangrene; common or external iliac arteries after suboptimal or failed balloon dilation; femoral, popliteal, or tibial arteries after suboptimal or failed balloon dilation; femoropopliteal lesions after a suboptimal balloon-dilation result; or infrapopliteal lesions after a suboptimal balloon-dilation result.
Examples of suboptimal or failed dilation include persistent translesional gradient, residual diameter stenosis greater than 50%, or flow-limiting dissection.
Popliteal artery aneurysm
- Aneurysm clinical or size criterion: The aneurysm is symptomatic, such as painful, pulsatile, or associated with clinical evidence of distal emboli, or is at least 2.0 cm on imaging even if asymptomatic.>= 2.0 cm
- High surgical risk: Documentation supports high perioperative surgical risk.
- Acceptable stent anatomy: Acceptable anatomy for stenting is documented and imaging specifically shows at least 15 mm of normal artery proximal and distal to the aneurysm.>= 15 mm normal artery proximal and distal

Named covered stents and venous indications

The following named devices and vascular applications are medically necessary when used for the listed indications.

Covered named devices and applications

Zilver PTX: Primary treatment of femoropopliteal artery disease.
Gore Viabahn PTFE-coated Endoprosthesis: Improving blood flow in persons with symptomatic peripheral arterial disease involving superficial femoral artery or iliac artery lesions.
Gore Viabahn stent: Treatment of failing stenotic or thrombosed hemodialysis grafts.
Gore Tigris Vascular Stent: Primary treatment of superficial femoral artery and proximal popliteal artery disease.

Renal artery stenting

Renal artery stenting for atherosclerotic renal artery stenosis is medically necessary when any one of the following criteria is met.

Atherosclerotic renal artery stenosis

Unilateral RAS with medical therapy intolerance or failure: Unilateral renal artery stenosis in a member intolerant to optimal medical therapy, including a clinically significant rise in serum creatinine after starting a renin-angiotensin system inhibitor, or failure of optimal medical therapy to control blood pressure.
Bilateral hemodynamically significant RAS: Hemodynamically significant bilateral renal artery stenosis.> 75% of both arteries
Progressive kidney impairment: Progressive kidney function impairment thought to result from the stenosis, or progressive impairment thought to be a consequence of bilateral renovascular disease or unilateral stenosis affecting a solitary functioning kidney.

Experimental or investigational indications

The following indications and technologies are considered experimental and investigational because effectiveness has not been established.

Experimental or investigational peripheral vascular stenting and atherectomy

Peripheral artery stenting indications: Celiac artery stenting for celiac artery compression syndrome; primary therapy for tibial artery stenosis or occlusions; primary therapy for infrapopliteal lesions; primary or salvage therapy for atherosclerotic renovascular disease such as ischemic nephropathy; primary or salvage therapy for aortoiliac arterial lesions; or renal artery stenting for fibromuscular dysplasia.
iCast/Gore Viabahn VBX: Treatment of celiac artery pseudoaneurysm.
Peripheral venous stents for recurrent phlebitis: Treatment of recurrent phlebitis.
Biodegradable stents:

Services that do not meet the listed clinical criteria are denied as not medically necessary. Services not listed with clinical criteria, along with specified experimental or investigational stent, atherectomy, arterialization, and other vascular indications, are excluded from medically necessary coverage.

For Family Health Center members, the surgical services addressed by this policy are not covered when performed in an inpatient, outpatient surgery, observation, or ambulatory surgical setting.

For BadgerCare Plus and Medicaid SSI, coverage and reimbursement are subject to the ForwardHealth interactive fee schedule, including payable services, provider types and specialties, and places of service. Professional claims submitted on a CMS-1500 may be denied as not covered under the Medicaid fee schedule, and facility claims submitted on a UB-04 are not separately reimbursable.

A peripheral vascular stent service is not medically necessary when it does not meet the policy's listed clinical criteria. Services without listed clinical criteria are considered experimental or investigational.

The specified experimental or investigational indications and technologies are not medically necessary because effectiveness has not been established. These include selected peripheral artery and venous stenting indications, biodegradable stents, hybrid foot vein arterialization, the LimFlow Stent Graft System, other drug-eluting or PTFE-covered arterial stents outside the named covered exceptions, selected drug-eluting stent applications, and mechanical or laser atherectomy of specified vessels. The list is not all-inclusive; other unlisted indications are also considered experimental or investigational.

Clinical Thresholds and Measurement Values

Popliteal artery aneurysm size

Imaging thresholdAt least 2.0 cm

Clinical alternativeA symptomatic aneurysm also qualifies, including one that is painful, pulsatile, or associated with distal emboli.

Treatment contextApplies to primary or salvage therapy for popliteal artery aneurysm.

Normal artery length around popliteal aneurysm

Proximal normal arteryAt least 15 mm proximal to the aneurysm

Distal normal arteryAt least 15 mm distal to the aneurysm

Documentation requirement

Documentation, Billing, and Denial Prevention

Documentation Required

Document the indication and treatment details

Document the indication, arterial or venous location, whether treatment is primary or salvage, symptoms and ischemic complications where applicable, and the clinical result of balloon dilation when salvage therapy is requested.

Documentation Required

Support popliteal aneurysm stenting criteria

For popliteal artery aneurysm stenting, document symptoms or imaging showing an aneurysm at least 2.0 cm, high perioperative surgical risk, acceptable anatomy, and imaging demonstrating at least 15 mm of normal artery both proximal and distal to the aneurysm.

The aneurysm must be symptomatic or at least 2.0 cm on imaging, even if asymptomatic.
Document high perioperative surgical risk.
Document acceptable anatomy and at least 15 mm of normal artery proximal and distal to the aneurysm.

Clinical Background

Peripheral artery disease is a chronic disorder in which narrowed or occluded arteries reduce blood flow, most often to the lower extremities, although other vascular beds may be involved. Severity ranges from exercise-related claudication to chronic limb-threatening ischemia with rest pain, nonhealing wounds, or gangrene. Endovascular treatment may include angioplasty, atherectomy, and stent placement to restore or maintain vessel patency; this policy distinguishes covered primary or salvage uses from unsupported experimental or investigational uses.

Clinical Terms and Procedure Definitions

Peripheral artery disease (PAD)

DefinitionA chronic circulation disorder in which arteries supplying the extremities are abnormally narrow and cannot keep up with demand.

Usual locationPAD occurs most often in the lower extremities.

Common causeAtherosclerosis, involving fatty plaque accumulation, is often a cause.

Claudication

DefinitionFatigue, discomfort, cramping, or vascular-origin pain in the lower-extremity muscles.

Exercise relationshipSymptoms are consistently caused by exercise.

Relief pattern

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyPeripheral Vascular Stents

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJune 1, 2026

Next Review DateN/A

Key ActionDocument the indication, vascular location, treatment type, symptoms, ischemic complications, and clinical result of balloon dilation when applicable.

SourceLink

On This Page

Eluvia Drug-Eluting Vascular Stent System: Primary treatment of superficial femoral artery and proximal popliteal artery disease.

LifeStream balloon-expandable covered stent: Primary treatment of iliac artery stenosis.

Peripheral venous stents: Hemodialysis access graft or fistula stenosis, restenosis, or occlusion; recurrent cephalic arch stenosis as salvage therapy; May-Thurner syndrome; or superior vena cava syndrome, post-radiation venous stenosis, or congenital stenosis.

Not an all-inclusive list.

Iliocaval venous occlusion: Balloon angioplasty and stenting for treatment of iliocaval venous occlusion.

Flash pulmonary edema or refractory heart failure: Recurrent flash pulmonary edema and/or refractory heart failure due to renal artery stenosis.

Unexplained progressive renal insufficiency, especially when proteinuria is absent.

Treatment of peripheral arterial disease using bioabsorbable or bioresorbable stents.

Hybrid foot vein arterialization: Treatment of critical or chronic limb ischemia.

LimFlow Stent Graft System: Treatment of critical or chronic limb ischemia.

Other drug-eluting or PTFE-covered arterial stents: Treatment of peripheral vascular disease with drug-eluting arterial stents or PTFE-covered arterial stents other than the Gore Viabahn PTFE-coated stent and Zilver PTX drug-eluting stent.

Examples include the Atrium Medical iCast stent.

Gore Viabahn for renal artery aneurysm: Treatment of renal artery aneurysm.

The indication has limited evidence and is not FDA-approved.

Drug-eluting stent non-covered indications: Use for aorto-arteritis/Takayasu arteritis; arteriovenous graft outflow vein stenosis in a person undergoing hemodialysis; chronic kidney disease with multivessel disease; coronary artery aneurysms; benign or malignant esophageal stricture or dysphagia; gastric outlet obstruction; myocardial bridging; pancreatobiliary disease or bile duct obstruction, including ERCP use; pulmonary vein stenosis; stenotic lesions of non-coronary arteries such as carotid, intracranial, peripheral, renal, or vertebral arteries; vein graft stenosis; or venous stenosis associated with dialysis vascular access.

Not an all-inclusive list.

Mechanical or laser peripheral atherectomy: Atherectomy of the renal artery, abdominal aorta, brachiocephalic trunk and branches, or iliac artery.

Imaging must specifically demonstrate the normal artery length on both sides of the aneurysm.

Residual diameter stenosis after balloon dilation

Residual stenosis thresholdGreater than 50% residual diameter stenosis after balloon dilation

Treatment roleThis is an example of a suboptimal or failed balloon-dilation result supporting salvage therapy.

Other suboptimal resultsPersistent translesional gradient or flow-limiting dissection also represent suboptimal or failed dilation.

Chronic ischemia duration

Duration thresholdMore than 2 weeks

Associated symptomChronic ischemic rest pain

Clinical significanceRest pain lasting more than two weeks is a defining feature of critical or chronic limb ischemia when attributable to objectively proven arterial occlusive disease.

Severe ischemia by toe pressure

Severe ischemia thresholdToe pressure lower than 30 mmHg

Clinical interpretationConsidered severely ischemic

Diagnostic significanceDiagnostic of critical limb ischemia when associated with the clinical context.

Severe ischemia by TBI

Severe ischemia thresholdTBI less than 0.2

Clinical interpretationConsidered severely ischemic

Diagnostic significanceDiagnostic of critical limb ischemia when associated with the clinical context.

Normal TcPO2

Normal TcPO2 thresholdGreater than 55 mmHg

Measurement scopeConsidered normal regardless of the site of measurement.

Clinical useTcPO2 supports assessment of peri-wound oxygenation, peripheral arterial disease, and critical limb ischemia.

Critical TcPO2

Critical TcPO2 value40 mmHg

Wound-healing implicationBelow this value, wound healing is impaired.

Ischemia implicationBelow this value, ischemia develops.

Bilateral renal artery stenosis

Bilateral stenosis thresholdMore than 75% of both renal arteries

Hemodynamic significanceThe bilateral renal artery stenosis must be hemodynamically significant.

Coverage contextThis is one criterion for medically necessary renal artery stenting for atherosclerotic renal artery stenosis.

Documentation Required

Document the qualifying renal artery stenosis findings

For renal artery stenting, document the applicable medical-therapy intolerance or failure, degree and laterality of stenosis, renal function progression, solitary-kidney or bilateral disease, pulmonary edema or refractory heart failure, and other evidence supporting the selected criterion.

For bilateral disease, document hemodynamically significant stenosis of more than 75% of both renal arteries.
Document a clinically significant serum creatinine rise after initiation of a renin-angiotensin system inhibitor or failure of optimal medical therapy to control blood pressure, when applicable.
Document progressive kidney impairment, recurrent flash pulmonary edema, refractory heart failure, or unexplained progressive renal insufficiency when applicable.

Documentation Required

Verify the applicable benefit document

Verify the member's Schedule of Benefits and Certificate, or for TPA members the Summary Plan Description, to determine applicable benefits and limitations before determining coverage.

Documentation Required

Include objective ischemia testing

When chronic or critical limb ischemia is used to support medical necessity, document objective arterial disease testing such as ABI, TBI, TcPO2, oxygen tension, or skin perfusion pressure testing.

Chronic ischemic rest pain must be greater than two weeks when used as a qualifying finding.
A toe pressure lower than 30 mmHg or TBI below 0.2 is considered severely ischemic.
A TcPO2 greater than 55 mmHg is generally normal; 40 mmHg is the critical value below which wound healing is impaired and ischemia develops.

Denial Risk

Confirm that the service meets listed criteria

Services that do not meet the listed clinical criteria are denied as not medically necessary. Services not listed with clinical criteria are considered experimental or investigational.

Denial Risk

Avoid unsupported experimental or investigational indications

Peripheral stenting, drug-eluting or covered stents, biodegradable stents, hybrid foot vein arterialization, LimFlow, and peripheral atherectomy are denied as experimental or investigational when used for the specified unsupported indications or other unlisted indications.

Examples include primary tibial or infrapopliteal treatment, aortoiliac arterial lesions, renal artery fibromuscular dysplasia, and hybrid foot vein arterialization or LimFlow for critical or chronic limb ischemia.
Other specified unsupported uses include biodegradable peripheral arterial stents, certain drug-eluting or PTFE-covered stents, Gore Viabahn for renal artery aneurysm, and specified mechanical or laser atherectomy.

Billing Rule

Verify Medicaid billing and reimbursement rules

For BadgerCare Plus and Medicaid SSI, claims must comply with the ForwardHealth fee schedule, including payable services, provider types, specialties, and places of service; professional claims may be denied as not covered and facility claims are not separately reimbursable.

Verify the applicable requirements through the ForwardHealth interactive fee schedule.
Claims submitted on a professional claim form may be denied as not covered per the Medicaid Fee Schedule.
Claims submitted on a facility claim form are not separately reimbursable.

Denial Risk

Check the Family Health Center setting limitation

Family Health Center does not cover the surgical services addressed by this policy when performed in inpatient, outpatient surgery, observation, or ambulatory surgical settings.

Documentation Required

Apply the TPA plan-document requirements

Third-party administration groups must be evaluated against the member's Summary Plan Description; if it contains no specific criteria, the commercial criteria apply.

Review the Summary Plan Description for coverage, limitations, and exclusions.
No prior authorization is required, but the member must meet clinical criteria when the claim is submitted or payment could be impacted.

Symptoms are consistently relieved by rest within 10 minutes.

Critical/chronic limb ischemia (CLI)

Rest pain criterionChronic ischemic rest pain lasting more than two weeks.

Tissue-loss criteriaA nonhealing wound or ulcer, or gangrene in one or both legs.

Objective disease requirementThe condition must be attributable to objectively proven arterial occlusive disease demonstrated by ABI, TBI, TcPO2 or oxygen tension measurement, or skin perfusion pressure testing.

Toe-brachial index (TBI)

MeasurementThe toe-brachial index compares toe pressure with brachial pressure and is used to assess peripheral arterial disease.

Severe ischemiaToe pressure lower than 30 mmHg or TBI below 0.2 is considered severely ischemic and diagnostic of critical limb ischemia.

General normal rangeToe pressure of 70–110 mmHg or TBI greater than 0.5–0.75 is generally considered normal.

TcPO2

DefinitionTranscutaneous oxygen measurement, also called transcutaneous oximetry or oxygen tension measurement.

Clinical usesUsed for serial assessment of peri-wound oxygenation, classification of peripheral arterial disease, and diagnosis of critical limb ischemia.

Interpretive thresholdsGreater than 55 mmHg is generally normal; 40 mmHg is the critical value below which wound healing is impaired and ischemia develops.

Stent

DeviceA mesh or metal device.

PurposeSupports a vessel that has been cleared.

Clinical functionMaintains vessel patency.

Endovascular revascularization

DefinitionA catheter-based vascular procedure for treatment of vascular disease.

AccessUsually performed percutaneously, but it may also be performed through open arterial access after open exposure of the artery.

Treatment approachesOptions include angioplasty, atherectomy, and stenting.