CurrentUnitedHealthcarePolicy CS166ID.C

Lower Extremity Endovascular Procedures (for Idaho Only)

UnitedHealthcare policy (Idaho only, including Idaho Medicaid Plus) governing coverage of endovascular revascularization procedures (stents, angioplasty, atherectomy) for lower extremity ischemia, with specific clinical criteria, exclusions, definitions, and applicable CPT and ICD-10 codes listed for reference.

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Endovascular Procedures (for Idaho Only)

Policy CodePolicy CS166ID.C

Change TypeRevised criteria; added/removed CPT codes; designated IVL not medically necessary

Effective DateJun 1, 2026

Next Review Date

Key ActionMaintain legible medical records documenting history, exam, diagnostic test results, and that clinical criteria (e.g., ABI, imaging, supervised exercise therapy) are met and make available upon request.

POLICY UPDATE CHANGES

Revised medically necessary coverage criteria for endovascular revascularization procedures and retreatment for in-stent restenosis with imaging example wording changed from 'invasive angiography' to 'digital subtraction angiography'.

Added language that intravascular lithotripsy for treating lower extremity ischemia is unproven and not medically necessary due to insufficient evidence of efficacy.

Added numerous CPT codes (37254–37299 series and 0238T) to the Applicable Codes section.

Removed CPT codes 37220–37235 from the Applicable Codes section.

Added notation that CPT codes 0238T and the listed 372xx codes are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid.

7Key covered conditions/indications (summary)

7Primary unproven/excluded procedures/indications listed

100+Applicable CPT/ICD-10 codes referenced

~50CPT codes added or referenced

Coverage Summary

Scope: UnitedHealthcare policy (Idaho only, including Idaho Medicaid Plus) governing coverage of endovascular revascularization procedures (stents, angioplasty, atherectomy) for lower extremity ischemia. Subject: Lower Extremity Endovascular Procedures (Idaho). Status: CURRENT. Effective date: June 1, 2026. High-level overview: The policy defines medically necessary use of endovascular revascularization for Claudication and Chronic Limb-Threatening Ischemia with required conservative therapy attempts and objective testing (Ankle-Brachial Index and imaging); it excludes upper extremity procedures and lists specific procedures considered unproven or not medically necessary.

Quick thresholds and facts

Ankle-Brachial Index thresholdAnkle-Brachial Index ≤ 0.90

Imaging stenosis thresholdModerate‑severe stenosis ≥ 50% on duplex US, CTA, MRA, or digital subtraction angiography

Supervised Exercise Therapy durationMinimum 12 weeks (30–45 min active/session, ≥3×/week)

Major RCT highlightedBEST‑CLI (surgical vs endovascular; cohort1 surgical superior; cohort2 similar)

Policy scope / quick factApplies to Idaho (including Idaho Medicaid Plus); imaging example wording updated to 'digital subtraction angiography'

Medical-Necessity Criteria

Endovascular revascularization for non-limb-threatening Claudication (medically necessary)

Endovascular revascularization procedures (e.g., stents, angioplasty, and/or atherectomy) are proven and medically necessary for treating non-limb-threatening lower extremity ischemia in individuals with Claudication due to atherosclerotic disease of the aortoiliac and/or femoropopliteal arteries when ALL of the following criteria are met:

ALL of the following

Impaired ability to work and/or perform activities of daily living.
Conservative therapies
- At least 12 weeks of Supervised Exercise Therapy or a Structured Community-Based Exercise Program.
- Pharmacological therapy (e.g., lipid lowering therapy, antihypertensive therapy, antiplatelet therapy, and/or anticoagulants).

Not Covered / Unproven Indications

The brief explicitly designates intravascular lithotripsy (IVL) for treating lower extremity ischemia as unproven and not medically necessary due to insufficient evidence of efficacy. For CPT codes noted as not on the Idaho Medicaid Fee Schedule or for services that may be non-covered or excluded, providers are directed to consult the Idaho Medicaid Provider Handbook for additional information and billing guidance; medical record documentation and possible prior authorization may be required to assess coverage.

Coding (Applicable codes and notes)

Billing Rule

State fee schedule limitation

CPT codes 0238T and listed 3725x–3729x codes are not on the Idaho Medicaid Fee Schedule and therefore may not be covered; providers should verify Idaho Medicaid coverage prior to billing.

Adhere to guideline-directed therapy prior to revascularization for claudication.
Affected CPT codes: 0238T; 37254; 37255; 37256; 37257; 37258; 37259; 37260; 37261; 37262; 37263; 37264; 37265; 37266; 37267; 37268; 37269; 37270; 37271; 37272; 37273; 37274; 37275; 37276; 37277; 37278; 37279

Provider Actions / Documentation & Billing

Documentation Required

Medical record documentation

Maintain legible medical records documenting relevant medical history, physical exam, diagnostic test results, and documentation that clinical criteria (e.g., ABI, imaging, supervised exercise therapy) are met. Make records available upon request.

Make records available upon request.

Prior Authorization

Prior authorization implied for coverage review

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; inclusion of codes in policy does not guarantee reimbursement.

Clinical Evidence Summaries

Evidence summary: Endovascular revascularization (angioplasty, stents, stent grafts, atherectomy) is an established option for claudication and CLTI; choice of approach depends on lesion characteristics (location, length, calcification) and patient risk. The BEST-CLI trial found surgical bypass superior to endovascular therapy for the primary composite endpoint in patients with a suitable great saphenous vein (cohort 1) and similar outcomes between approaches in patients without a suitable vein (cohort 2). Systematic reviews and RCTs show supervised exercise and endovascular therapy produce comparable improvements in walking distance and quality of life for intermittent claudication, and combination therapy may yield greater benefit. Overall, comparative durability and long-term outcomes vary by technique and patient selection.

Study / Source	Key finding
BEST-CLI trial	Surgical bypass had lower incidence of major adverse limb event or death than endovascular in cohort 1 (suitable great saphenous vein); outcomes were similar in cohort 2; adverse events similar between groups.
Disrupt PAD III RCT	In heavily calcified femoropopliteal lesions, IVL (versus PTA) achieved higher procedural success and higher primary patency at 1 and 2 years, with similar major adverse events at 1 year.
DETOUR 2 study	Single-arm prospective trial: 100% technical success; 30-day freedom from major adverse events 93.0%; 12-month primary patency 72.1%; improvements in ABI and Rutherford class noted.
Iliac atherectomy evidence	Insufficient quality evidence (mostly retrospective/observational, heterogeneous); procedure uncommon due to risk of life‑threatening perforation; randomized data lacking.
Guidelines cited	Multisociety guidelines (ACC/AHA/SCAI/SIR/SVM, SVS, IWGDF, NICE) recommend guideline‑directed medical therapy and supervised/structured exercise before revascularization for claudication; note iliac atherectomy is rarely appropriate; both endovascular and surgical options appropriate for CLTI; NICE recommends IVL only with special arrangements.
Systematic reviews/meta-analyses	Systematic reviews and meta-analyses report endovascular therapy and supervised exercise are comparable for improving walking distance and quality of life in intermittent claudication; bypass may have lower reintervention rates but similar amputation/mortality; evidence on IVL and DETOUR is limited by study design and follow‑up.

Technology-specific implications: IVL is promising for preparation of calcified femoropopliteal lesions with improved procedural outcomes versus PTA in some trials, but longer-term durability and patient-centered outcome data are limited — the policy therefore designates IVL as not medically necessary for lower extremity ischemia. The DETOUR endovenous femoropopliteal bypass shows promising technical success, patency, and functional improvements in single-arm studies (DETOUR I/II), but comparative randomized data versus open bypass are lacking. Iliac artery atherectomy has insufficient quality evidence to support safety and efficacy and is uncommon due to risk of life‑threatening perforation.

Definitions

Ankle-Brachial Index: The Ankle-Brachial Index compares systolic blood pressure in the ankle with the systolic blood pressure in the arm; an ABI of less than 0.90 indicates peripheral artery disease.

CLTI: Chronic Limb-Threatening Ischemia is defined as chronic (≥ 2 weeks) ischemic rest pain, nonhealing wound/ulcers, or gangrene attributable to objectively proven arterial occlusive disease.

Claudication: Fatigue, cramping, aching, pain, or other discomfort of vascular origin in the lower extremity muscles induced by walking and relieved by rest; functionally limiting when it limits functional status.

Structured Community-Based Exercise Program: A home/community-based prescribed regimen similar to supervised exercise therapy, self-directed with healthcare guidance, counseling, may include behavioral change techniques and periodic supervised sessions.

Supervised Exercise Therapy: Facility-based, directly supervised intermittent walking exercise sessions with 30–45 minutes of active walking per 60-minute session, performed at least three times per week for a minimum of 12 weeks.

PAD: Peripheral artery disease — narrowing of vessels due to atherosclerosis limiting blood flow to the limbs.

IVL: Intravascular lithotripsy — uses acoustic pressure waves to modify calcified plaque to facilitate angioplasty.

DETOUR system: Endovenous femoropopliteal bypass using stents routed through the femoral vein to reestablish arterial flow in long occlusive superficial femoral artery lesions.

Revision History

2026-06-01revisedLatest

2026-06-01addedLatest

Added language that intravascular lithotripsy (IVL) for treating lower extremity ischemia is unproven and not medically necessary due to insufficient evidence of efficacy.

2026-06-01

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Endovascular Procedures (for Idaho Only)

Policy CodePolicy CS166ID.C

Change TypeRevised criteria; added/removed CPT codes; designated IVL not medically necessary

Effective DateJun 1, 2026

Next Review Date

On This Page

Smoking cessation, if applicable.

Ischemic peripheral artery disease with Ankle-Brachial Index of ≤ 0.90≤ 0.90

Imaging results of the target vessel (e.g., duplex ultrasound, CTA, MRA, or DSA) show anatomical location and a moderate-severe stenosis (50% or greater). If duplex ultrasound does not demonstrate a stenosis of 50% or greater, another imaging modality will be necessary to demonstrate the extent of stenosis.≥ 50%

Imaging wording updated: if duplex does not show ≤50% stenosis, obtain confirmatory CTA/MRA/DSA.

Retreatment for in-stent restenosis (medically necessary)

Retreatment of a previously treated vessel due to in-stent restenosis is proven and medically necessary for treating non-limb-threatening lower extremity ischemia in individuals with Claudication due to atherosclerotic disease of the aortoiliac and/or femoropopliteal arteries when ALL of the following criteria are met:

ALL of the following

Recurrent symptoms.
Impaired ability to work and/or perform activities of daily living.
Imaging results of the previously treated vessel (e.g., duplex ultrasound, CTA, MRA, or DSA) show anatomical location and a moderate-severe stenosis (50% or greater). If duplex ultrasound does not demonstrate a stenosis of 50% or greater, another imaging modality will be necessary to demonstrate the extent of stenosis.≥ 50%
Retreatment requires imaging demonstration of ≥ 50% stenosis; if duplex is non-diagnostic, obtain CTA/MRA/DSA.

Endovascular revascularization for Chronic Limb-Threatening Ischemia (medically necessary)

Endovascular revascularization procedures (e.g., stents, angioplasty and/or atherectomy) are proven and medically necessary for treating Chronic Limb-Threatening Ischemia (CLTI) when the diagnosis meets the policy definitions for CLTI (chronic \u2265 2 weeks of ischemic rest pain, nonhealing wound/ulcers, or gangrene attributable to objectively proven arterial occlusive disease).

ALL of the following

Diagnosis of Chronic Limb-Threatening Ischemia per policy definitions (chronic (≥ 2 weeks) ischemic rest pain, nonhealing wound/ulcers, or gangrene) or other applicable CLTI clinical criteria.

Medically Necessary Coverage Criteria (summary from policy part)

Medically Necessary Coverage Criteria (summary):

ALL of the following

Endovascular revascularization for non-limb-threatening Claudication: impaired function, failed conservative therapies (including ≥12 weeks supervised or structured community-based exercise, pharmacologic therapy, smoking cessation when applicable), ABI ≤ 0.90, and imaging-confirmed â‰¥50% stenosis (CTA/MRA/DSA if duplex is non-diagnostic).
Imaging wording updated: if duplex does not show ≤50% stenosis, obtain confirmatory CTA/MRA/DSA.
Retreatment for in-stent restenosis: recurrent symptoms, impaired function, and imaging-confirmed â‰¥50% stenosis on the previously treated vessel (CTA/MRA/DSA if duplex is non-diagnostic).
Retreatment requires imaging demonstration of ≥ 50% stenosis; if duplex is non-diagnostic, obtain CTA/MRA/DSA.
Endovascular revascularization for CLTI: CLTI diagnosis per policy definitions (chronic ischemic rest pain â‰¥2 weeks, nonhealing wound/ulcer, or gangrene) with objective arterial occlusive disease.
Clinical evidence summaries / implications
- Policy reflects evidence that endovascular revascularization is effective for function-limiting Claudication and for limb salvage in CLTI when selection criteria are met; conservative management including supervised exercise and optimal medical therapy should be attempted prior to intervention for Claudication.
- Evidence is insufficient to support routine endovascular intervention for asymptomatic disease, non-limb-threatening infrapopliteal disease, to prevent progression from Claudication to CLTI, or for certain techniques (transluminal peripheral atherectomy of the iliac artery, endovenous femoropopliteal bypass with stent graft, intravascular lithotripsy) which are considered unproven.
Not Medically Necessary / Unproven
- Interventions performed for non-limb-threatening infrapopliteal (anterior tibial, posterior tibial, or peroneal) artery disease are not medically necessary due to insufficient evidence of efficacy.
- Treatment of an asymptomatic individual is not medically necessary.
- Interventions to prevent progression of Claudication to CLTI are not medically necessary.
- Transluminal peripheral atherectomy of the iliac artery is unproven and not medically necessary.
- Endovenous femoropopliteal bypass using a stent graft is unproven and not medically necessary.
- Intravascular lithotripsy for lower extremity ischemia is unproven and not medically necessary.

Documentation Required

Use applicable ICD-10-CM diagnosis codes

When submitting claims for PAD-related procedures, include one of the listed ICD-10-CM diagnosis codes that accurately reflects the patient's condition. Codes marked with an asterisk may not be covered under the State of Idaho Medicaid Fee Schedule; refer to the Idaho Medicaid Provider Handbook for details.

Note: Codes labeled with an asterisk may not be covered — see Idaho Medicaid Provider Handbook.

Documentation Required

Imaging documentation requirement

Imaging examples for the target vessel must be documented for coverage decisions. Policy language has replaced the prior example of 'invasive angiography' with 'digital subtraction angiography' as an acceptable imaging modality when demonstrating ≥50% stenosis for intervention or retreatment.

Imaging wording change: 'digital subtraction angiography' replaced 'invasive angiography'.

Billing Rule

State fee schedule limitation

CPT codes 0238T and the listed 3725x–3729x series codes are not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by the State of Idaho Medicaid Program; providers should verify Idaho Medicaid coverage prior to billing.

Affected CPT codes: 0238T; 37254–37299 (listed 3725x–3729x series).
Verify Idaho Medicaid coverage prior to billing; refer to Idaho Medicaid Provider Handbook for non-covered/excluded services.

Added numerous CPT procedure codes (including 37254–37299 series and 0238T) to the Applicable Codes section; these are noted with an asterisk in the policy as not on the State of Idaho Medicaid Fee Schedule and therefore may not be covered by Idaho Medicaid.

2026-06-01removedLatest

Removed older CPT codes 37220–37235 from the Applicable Codes section.

2026-06-01clarifiedLatest

Added notation directing providers to the Idaho Medicaid Provider Handbook: codes labeled with an asterisk (including 0238T and many 3725x–3729x codes) are not on the State of Idaho Medicaid Fee Schedule and may not be covered.