CurrentUnitedHealthcarePolicy CSNCT0602.04

Lower Extremity Vascular Angiography Nc Cs

UnitedHealthcare medical policy (North Carolina only) defining medical necessity criteria, exclusions, and applicable procedure/diagnosis codes for endovascular revascularization procedures (stents, angioplasty, atherectomy) for lower extremity peripheral artery disease including claudication and chronic limb‑threatening ischemia (CLTI).

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Vascular Angiography Nc Cs

Policy CodePolicy CSNCT0602.04

Change TypeRevised & Added criteria; Documentation updates

Effective DateMar 1, 2026

Next Review Date

Key ActionDocument relevant medical history, physical exam and diagnostic test results supporting medical necessity and make records available upon request.

SourceLink

POLICY UPDATE CHANGES

Revised medically necessary coverage criteria for endovascular revascularization procedures for non-limb-threatening lower extremity ischemia (claudication), replacing imaging criterion wording with imaging of the target vessel showing moderate-severe stenosis (50% or greater).

Added language that retreatment for in-stent restenosis is proven and medically necessary when recurrent symptoms, impaired ADLs/work, and imaging showing ≥50% stenosis are present.

Added documentation language clarifying that benefit coverage is determined by federal/state/contractual requirements and that medical records may be required for review.

Updated Clinical Evidence and References sections to reflect current information; archived previous policy version CSNCT0602.03.

3Core coverage categories (Claudication, Retreatment for ISR, CLTI)

Unproven / Not covered indication examples listed

>=50%Stenosis threshold for imaging-defined moderate-severe disease

20+Applicable diagnosis codes listed

1FDA/Device info noted (DETOUR system PMA referenced)

Coverage Summary

This UnitedHealthcare North Carolina medical policy CSNCT0602.04 (Effective March 1, 2026) addresses coverage for lower extremity endovascular revascularization procedures for peripheral artery disease (PAD), including angioplasty, stents, and atherectomy. Core coverage categories include: treatment of lifestyle-limiting Claudication (non‑limb‑threatening ischemia) when conservative therapies fail and objective criteria are met; Retreatment for in‑stent restenosis when recurrent symptoms and imaging-confirmed ≥ 50% stenosis are present; and treatment of Chronic Limb‑Threatening Ischemia (CLTI) when diagnosis codes and CLTI criteria are met. The overall coverage stance is mixed: certain endovascular interventions are proven and medically necessary under specific conditions, whereas several indications and particular procedures are designated unproven/not medically necessary due to insufficient evidence.

Surface thresholds and quick facts

Ankle-Brachial Index (ABI)≤ 0.90

Stenosis degree on imaging≥ 50% (moderate–severe stenosis)

Supervised Exercise Therapy duration≥ 12 weeks

IWGDF urgent vascular thresholds (informational)Ankle pressure <50 mmHg or ABI <0.4; Toe pressure <30 mmHg; TcPO2 <25 mmHg

Retreatment (in‑stent restenosis)Recurrent symptoms + impaired ADLs/work + imaging stenosis ≥50%

FDA approval status (informational)DETOUR System PMA: June 7, 2023

Medical-Necessity Criteria

Endovascular revascularization for non-limb-threatening Claudication

Covered when ALL of the following are met:

ALL of the following

Conservative therapies tried and failed
- At least twelve (12) weeks of Supervised Exercise Therapy or a Structured Community-Based Exercise ProgramSupervised Exercise Therapy ≥ 12 weeks
- Pharmacologic therapy (e.g., lipid lowering therapy, antihypertensive therapy, antiplatelet therapy, and/or anticoagulants)
- Smoking cessation, if applicable

Not Medically Necessary / Unproven Indications

Rationale: the policy explicitly identifies interventions judged unproven because of insufficient evidence of efficacy (for example, iliac artery atherectomy and endovenous femoropopliteal bypass with stent graft), and limits coverage to situations supported by objective criteria and clinical need. The evidence summary emphasizes limited quality data, mostly single‑arm or observational studies for some techniques, and incomplete comparative data for novel approaches, which underpins the designation of those listed interventions as not medically necessary.

Coding

Primary CPT / HCPCS Procedure Codes (referenced in policy)CPT

0238T	Transluminal peripheral atherectomy, open or percutaneous; iliac artery, each vessel
0505T	Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure
37220	Revascularization, endovascular, iliac artery, unilateral, initial vessel; with transluminal angioplasty
37221	Revascularization, endovascular, iliac artery, unilateral, initial vessel; with transluminal stent placement(s)
37222	Revascularization, endovascular, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty
37223	Revascularization, endovascular, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s)
37224	Revascularization, endovascular, femoral, popliteal artery(s), unilateral; with transluminal angioplasty
37225	Revascularization, endovascular, femoral, popliteal artery(s), unilateral; with atherectomy
37226	Revascularization, endovascular, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s)
37227	Revascularization, endovascular, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy

1–10 of 18

1/2

Codes noted as unproven / not medically necessaryCPTNot Covered

0238T	Transluminal peripheral atherectomy; iliac artery (listed in unproven indications)
0505T	Endovenous femoropopliteal arterial revascularization with stent graft (endovenous femoropopliteal bypass using a stent graft referenced as unproven)

Applicable Diagnosis Codes (ICD-10) referenced for CLTI and PADICD-10

E08.52	Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E09.52	Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.52	Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.52	Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.52	Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
I70.221	Atherosclerosis of native arteries of extremities with rest pain, right leg
I70.222	Atherosclerosis of native arteries of extremities with rest pain, left leg
I70.223	Atherosclerosis of native arteries of extremities with rest pain, bilateral legs
I70.228	Atherosclerosis of native arteries of extremities with rest pain, other extremity
I70.229	Atherosclerosis of native arteries of extremities with rest pain, unspecified extremity

1–10 of 36

1/4

Additional ICD-10 and related codes listedICD-10

M86.051	Acute hematogenous osteomyelitis, right femur
M86.052	Acute hematogenous osteomyelitis, left femur
M86.059	Acute hematogenous osteomyelitis, unspecified femur
Q27.30	Arteriovenous malformation, site unspecified
Q27.32	Arteriovenous malformation of vessel of lower limb
Q87.2	Congenital malformation syndromes predominantly involving limbs
S35.511A	Injury of right iliac artery, initial encounter
T82.312A	Breakdown (mechanical) of femoral arterial graft (bypass), initial encounter

Regulatory / Device information (informational)mixed

PMA product codes NIO, NIP, DQY (FDA reference)

FDA product codes referenced for stents/stent systems and catheter systems used for PAD (informational)

Provider Actions & Documentation Requirements

Documentation Required

Medical record documentation required

The patient's medical record must contain documentation that fully supports the medical necessity for the requested lower extremity vascular angiography or related endovascular procedures. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws; submission of documentation for review does not guarantee coverage. Documentation should be legible, maintained in the patient's medical record, and made available upon request.

Relevant medical history (e.g., symptom onset, Claudication severity and functional limitation, prior interventions, risk factors such as smoking, diabetes, hyperlipidemia, hypertension)
Physical examination findings (e.g., pulses, wound descriptions, signs of ischemia, ABI results)
Pertinent diagnostic test results (e.g., ABI/TPIs, duplex ultrasound, CTA, MRA, digital subtraction angiography, laboratory studies)
Conservative therapy trials and response (see separate entry below for required documentation)
Treatment plan and rationale for angiography or revascularization, including anatomic targets

Background & Evidence Summary

Background: Peripheral artery disease (PAD) is atherosclerotic narrowing of lower extremity arteries that can reduce limb blood flow and cause claudication and, when severe, chronic limb‑threatening ischemia (CLTI). Treatment options include lifestyle modification, medical therapy, endovascular techniques (balloon angioplasty, stents, endovenous stent grafts, and atherectomy), and surgical bypass; choice of technique depends on lesion characteristics such as anatomic location, lesion length, and calcification. The policy details indications and objective thresholds for endovascular revascularization and for retreatment of in‑stent restenosis.

Evidence source	Key point
Pegler et al. 2025 (systematic review/meta-analysis)	No significant difference in major amputation or mortality between bypass and endovascular groups; bypass had lower reintervention rate.
BEST-CLI trial (Farber et al., 2022)	Included in evidence base; in Cohort 1 surgical bypass had lower incidence of major adverse limb event or death vs endovascular; Cohort 2 outcomes similar between groups. Trial referenced in review; details summarized in policy.
DETOUR2 trial (Lyden et al., 2024)	100% technical success; 30-day freedom from major adverse events 93.0%; 1-year primary patency 72.1%; 12‑month DVT incidence 4.1%; single‑arm study without randomized comparator.
Iliac atherectomy evidence	Insufficient quality evidence to support safety and efficacy; studies largely retrospective, single‑arm, or nonrandomized; procedure uncommon due to risk of life‑threatening perforation.
Trial details referenced but not expanded	Policy cites BEST‑CLI within Pegler review and summarizes DETOUR (DETOUR I/DETOUR2) and iliac atherectomy evidence; some trial details are noted but not fully expanded in this policy section.

Definitions

Ankle‑Brachial Index (ABI): The ABI compares systolic blood pressure in the ankle to the arm; an ABI < 0.90 indicates peripheral artery disease.

Chronic Limb‑Threatening Ischemia (CLTI): Chronic (≥ 2 weeks) ischemic rest pain, nonhealing wounds/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 that is consistently induced by walking and relieved by rest.

Structured Community‑Based Exercise Program: A home/community program prescribed by qualified healthcare professionals, self‑directed with guidance, may include periodic supervised sessions and behavioral support.

Supervised Exercise Therapy: Facility‑based, directly supervised exercise (typically treadmill), with training to achieve 30–45 minutes of active walking per session, performed ≥ 3 times/week for a minimum of 12 weeks.

CLTI (alternate): Severe PAD with high risk of limb loss, synonymous with chronic limb‑threatening ischemia and distinct from acute limb ischemia.

Revision History

03/01/2026revisedLatest

Revised medically necessary coverage criteria for endovascular revascularization for non-limb‑threatening claudication: replaced prior imaging wording with requirement that imaging results of the target vessel (e.g., duplex ultrasound, CTA, MRA, or digital subtraction angiography) show anatomic location and a moderate‑severe stenosis (50% or greater).

03/01/2026added (material)Latest

Added retreatment language: retreatment of a previously treated vessel for in‑stent restenosis is proven and medically necessary when all criteria are met — recurrent symptoms, impaired ability to work/perform ADLs, and imaging of the previously treated vessel showing anatomic location and a moderate‑severe stenosis (50% or greater); if duplex ultrasound does not show ≥50% stenosis, another imaging modality is required.

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Vascular Angiography Nc Cs

Policy CodePolicy CSNCT0602.04

Change TypeRevised & Added criteria; Documentation updates

Effective DateMar 1, 2026

Next Review Date

Key ActionDocument relevant medical history, physical exam and diagnostic test results supporting medical necessity and make records available upon request.

SourceLink

On This Page

Impaired ability to work and/or perform activities of daily living (ADL)

Ankle-Brachial Index (ABI): Ischemic peripheral artery disease with Ankle-Brachial Index (ABI) ≤ 0.90ABI ≤ 0.90

Imaging stenosis threshold: Imaging results of the target vessel (e.g., duplex ultrasound, CTA, MRA, or digital subtraction angiography) show anatomic location and a moderate-severe stenosis (50% or greater); if duplex ultrasound does not demonstrate a stenosis 50% or greater, another imaging modality will be necessary to demonstrate the extent of stenosisstenosis ≥ 50%

If duplex ultrasound does not show ≥50% stenosis, another imaging modality is required to demonstrate extent of stenosis.

Retreatment for in-stent restenosis (non-limb-threatening Claudication)

Covered when ALL of the following are met:

ALL of the following

Retreatment for in-stent restenosis criteria
- Recurrent symptoms
- Impaired ability to work and/or perform activities of daily living (ADL)
- Imaging of previously treated vessel: Imaging results of the previously treated vessel (e.g., duplex ultrasound, CTA, MRA, or digital subtraction angiography) show anatomic 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 stenosisstenosis ≥ 50%
  If duplex ultrasound does not show ≥50% stenosis, another imaging modality is required.

Endovascular revascularization for Chronic Limb-Threatening Ischemia (CLTI)

Covered for treating CLTI when diagnosis meets Applicable Codes

Diagnosis consistent with CLTI (chronic ≥ 2 weeks ischemic rest pain, nonhealing wound/ulcers or gangrene attributable to objectively proven arterial occlusive disease)

Medically Necessary Coverage Criteria for Endovascular Revascularization (summary of changes reflected)

Covered when ALL of the following are met:

Medically necessary checklist

Diagnosis of non-limb-threatening lower extremity ischemia (Claudication) due to atherosclerotic disease of the aortoiliac and/or femoropopliteal arteries
Conservative therapy: Refractory to guideline-directed medical therapy and structured/supervised exercise (documentation of trial and failure of at least 12 weeks of supervised or structured community-based exercise, pharmacologic therapy, and smoking cessation efforts if applicable)Supervised Exercise Therapy ≥ 12 weeks
Imaging results of the target vessel (e.g., duplex ultrasound, CTA, MRA, or digital subtraction angiography) show anatomic location and a moderate-severe stenosis (50% or greater); if duplex ultrasound does not demonstrate a stenosis 50% or greater, another imaging modality will be necessary to demonstrate the extent of stenosisstenosis ≥ 50%
If duplex ultrasound does not show ≥50% stenosis, another imaging modality is required.
Symptom severity: Documentation demonstrates symptoms are lifestyle-limiting (impaired ability to work and/or perform activities of daily living) or recurrent symptoms in retreatment scenarios

Retreatment for In-Stent Restenosis (Proven and Medically Necessary)

Covered when ALL of the following are met:

ALL of the following

Previously treated vessel with stent and evidence of in-stent restenosis
Recurrent symptoms
ADL impairment: Impaired ability to work and/or perform activities of daily living (ADL)
Imaging threshold: Imaging results of the previously treated vessel (e.g., duplex ultrasound, CTA, MRA, or digital subtraction angiography) show anatomic location and a moderate-severe stenosis (50% or greater); if duplex ultrasound does not demonstrate a stenosis of 50% or greater, another imaging modality is necessary to demonstrate the extent of stenosisstenosis ≥ 50%
If duplex ultrasound does not demonstrate ≥50% stenosis, another imaging modality is required.

Prior Authorization

Imaging requirement for stenosis verification

Imaging must document the anatomic location and degree of stenosis in the target vessel. If duplex ultrasound does not demonstrate a stenosis of 50% or greater, an additional imaging modality is required to verify stenosis (CTA, MRA, or digital subtraction angiography). Provide imaging reports and, when available, images or operative/angiographic reports that clearly state percent stenosis and lesion location.

Acceptable modalities: duplex ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA), digital subtraction angiography (DSA)
If duplex ultrasound < 50% stenosis → obtain CTA, MRA, or DSA to demonstrate extent of stenosis
For retreatment/in-stent restenosis: provide imaging of the previously treated segment documenting ≥ 50% restenosis or other objective lesion description

Documentation Required

Conservative therapy documentation

For coverage consideration of endovascular revascularization for Claudication, document prior conservative therapy trials. This includes a minimum 12-week supervised or structured community-based exercise program, pharmacologic therapies, and smoking cessation attempts when applicable. Include dates, duration, frequency, and provider oversight details.

Supervised Exercise Therapy: documentation of at least 12 weeks (minimum 3 sessions/week; sessions typically 30–45 minutes active walking per session) or description of participation in a Structured Community-Based Exercise Program with equivalent content and monitoring
Pharmacologic therapy: evidence of appropriate medication trials (e.g., antiplatelet agents, statins/lipid-lowering therapy, antihypertensives) and adherence as applicable
Smoking cessation: documentation of counseling, pharmacotherapy, or participation in cessation programs when the member is a current smoker

Prior Authorization

Coverage determination may require review of clinical criteria

Coverage determinations may require review of clinical criteria and supporting documentation. Federal, state, or contractual rules and applicable laws govern benefit coverage and may mandate or restrict coverage for specific services. Submission of medical records and imaging for review is evaluated against policy criteria but does not guarantee that the service will be covered.

Documentation submitted for prior authorization or retrospective review must support all required clinical criteria for the requested service
Local/state mandates or contractual provisions may supersede portions of this policy where applicable
Provision of documentation is not a guarantee of payment; final determination is based on benefit coverage, coding, and applicable rules

03/01/2026added (non-material)Latest

Added documentation language clarifying benefit coverage is determined by federal/state/contractual requirements and that medical records (relevant history, physical exam, and diagnostic test results) may be required and must be made available upon request.

03/01/2026updatedLatest

Updated Clinical Evidence and References sections to reflect current information; archived previous policy version CSNCT0602.03.