UnitedHealthcare lower extremity endovascular Prior Auth

Coverage and Medical Necessity Criteria

General medical necessity

Covered when clinical criteria are met per InterQual and guideline-concordant care:

General coverage: Endovascular revascularization procedures (e.g., stents, angioplasty, and/or atherectomy) for treatment of lower extremity ischemia are medically necessary in certain circumstances when medical necessity is established using InterQual CP: Procedures, Endovascular Intervention, Peripheral Artery.

InterQual determines specific inclusion/exclusion details.

Conservative therapy requirement

Conservative therapy prior to revascularization for intermittent claudication:

Conservative care requirement: Patients with intermittent claudication should first receive guideline-directed medical therapy (risk factor modification, optimal medical therapy) and structured exercise/supervised exercise therapy; revascularization should be considered only for patients with lifestyle-limiting claudication despite these noninvasive approaches.

Per multi-society appropriate use criteria and SVS guidance.

Covered when ALL/ANY of the following

Revascularization (endovascular or surgical) is appropriate when patients meet guideline-based indications and have failed or are unsuitable for conservative therapy, or when presenting with CLTI requiring limb salvage.

General prerequisites: Patient has symptomatic peripheral artery disease (intermittent claudication that limits lifestyle or chronic limb‑threatening ischemia) AND guideline-directed medical therapy and structured exercise have been attempted or are not appropriate for the patient.

Based on ACC/AHA, SCAI, SVS recommendations.

Hemodynamic or wound-based urgency for revascularization: Ankle pressure <50 mmHg OR ankle–brachial index (ABI) <0.4 OR toe pressure <30 mmHg OR transcutaneous oxygen pressure (TcPO2) <25 mmHg OR extensive tissue loss/infection in which higher pressures may prompt revascularization.

IWGDF guidance.

Device-specific indication (DETOUR System): For symptomatic femoropopliteal lesions meeting device labeling, lesion length within DETOUR System PMA limits (approximately 200–460 mm; chronic total occlusions 100–425 mm) may be considered when the patient is an appropriate candidate and surgical or alternative endovascular approaches are suboptimal or not feasible.

Transluminal peripheral atherectomy of the iliac artery is considered not medically necessary because the evidence is insufficient to demonstrate safety and efficacy. Published studies are primarily retrospective, single‑arm, or nonrandomized, include small and heterogeneous patient populations and device types, and lack adequate comparative data versus angioplasty or stenting. Procedural risks, including the potential for life‑threatening perforation, have been described and contribute to the conclusion that iliac artery atherectomy remains unproven for routine use.

Endovenous femoropopliteal bypass using the DETOUR system is considered investigational / not medically necessary because current evidence is limited to single‑arm, nonrandomized studies and there are insufficient comparative data to establish superiority or equivalent patient‑centered outcomes versus open surgical bypass or alternative endovascular approaches. Although early single‑arm studies reported acceptable technical success and patency rates, the overall quality of evidence is very low and larger randomized comparative trials are needed to define safety and effectiveness.

Revascularization should not be performed for patients with asymptomatic PAD or for those with intermittent claudication based solely on hemodynamic measurements or imaging findings. Guideline panels recommend conservative management first and note there is no evidence that revascularization alters disease progression in asymptomatic individuals; interventions are reserved for lifestyle‑limiting symptoms that persist despite guideline‑directed medical therapy and structured exercise.

For patients with intermittent claudication and no signs of chronic limb‑threatening ischemia (CLTI), infrapopliteal revascularization is generally not recommended. The Society for Vascular Surgery advises against infrapopliteal interventions in this population because evidence of benefit is lacking and procedures may introduce potential harm.

Iliac artery atherectomy is explicitly designated not medically necessary. The rationale includes insufficient quality evidence of efficacy, predominance of retrospective and nonrandomized study designs, small sample sizes with heterogeneous lesion and device characteristics, and documented safety concerns such as the risk of vessel perforation. These limitations prevent demonstrating a favorable benefit–risk profile compared with established therapies.

Atherectomy of the iliac artery is regarded as rarely appropriate because there are no robust data showing benefit compared with angioplasty and stenting. Guideline and appropriate‑use statements emphasize selecting revascularization strategies based on lesion location, length, calcification, and comparative evidence; without supportive comparative trials, iliac atherectomy is not routinely recommended and revascularization should be directed by established indications.

Applicable Codes and Device Identifiers

Applicable CPT and Category III codesCPT

0238T	Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel.
0505T	Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion.
37220	Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty.
37221	Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed.
37222	Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure).
37223	Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when.
37224	Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty.
37225	Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed.
37226	Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed.
37227	Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed.

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Device PMA identifiersmixed

P220021

FDA PMA identifier for the DETOUR System

DETOUR System lesion length — FDA approval

FDA-approved lesion length (femoropopliteal)200 mm to 460 mm for symptomatic femoropopliteal lesions

Chronic total occlusion (CTO) length100 mm to 425 mm for CTOs included in the approval

Diffuse stenosis criterionDiffuse stenosis > 70% within the treated segment considered in approval

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

InterQual-based prior authorization

Prior authorization is required and is based on InterQual® CP: Procedures, Endovascular Intervention, Peripheral Artery. Requests for endovascular revascularization procedures (e.g., stents, angioplasty, atherectomy) will be reviewed using InterQual criteria to determine medical necessity.

InterQual is the primary clinical decision tool for prior authorization of endovascular interventions
Examples: peripheral angioplasty, stent placement, atherectomy

Prior Authorization

Prior authorization and criteria source

UnitedHealthcare uses InterQual as the primary source for clinical review. If InterQual does not contain applicable criteria for a specific request, UnitedHealthcare may apply its Medical Policies, Coverage Determination Guidelines, and/or Utilization Review Guidelines that have been approved by the Ohio Department of Medicaid Services. Verification of benefit coverage must consider federal, state (Ohio Administrative Code), and contractual requirements; in the event of a conflict, those requirements govern.

Primary criteria source: InterQual® CP: Procedures, Endovascular Intervention, Peripheral Artery

Clinical Background

Peripheral artery disease (PAD) is atherosclerotic narrowing of leg arteries that can present as claudication (exercise‑induced leg pain relieved by rest) or progress to chronic limb‑threatening ischemia (CLTI), which carries risk of limb loss if untreated. Management ranges from lifestyle modification, medical therapy, and supervised exercise for intermittent claudication to endovascular or surgical revascularization for patients with lifestyle‑limiting symptoms unresponsive to conservative care or with CLTI requiring limb salvage.

Key Definitions

Peripheral artery disease (PAD)

DefinitionPeripheral artery disease (PAD) is a narrowing of vessels due to atherosclerosis that limits blood flow to the limbs, most commonly affecting arteries in the legs.

Common symptomsMany people are asymptomatic; symptomatic patients may have leg pain, numbness, or cramping during exercise (claudication)

Clinical significancePAD is associated with increased risk of heart attack, stroke, and can progress to chronic limb‑threatening ischemia (CLTI) if untreated

Claudication

DefinitionClaudication is leg pain, numbness, or cramping that occurs during exercise and is relieved by rest.

Typical triggerSymptoms are exertional—provoked by walking or exertion and improve with cessation of activity

Policy Revision History

2026-02-01policy_revisionLatest

Added and operationalized medical records documentation expectations clarifying that medical records may be required to assess whether members meet clinical criteria for coverage and do not guarantee coverage; specified required documentation elements and availability upon request.

OpenPayer

Lower Extremity Endovascular Procedures (for Ohio Only)