ModifiedUnitedHealthcarePolicy CS166NM.C

Lower Extremity Endovascular Procedures (for New Mexico Only)

Medically necessary and not medically necessary indications, criteria, and applicable codes for endovascular revascularization procedures of the lower extremities for New Mexico members.

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Endovascular Procedures (for New Mexico Only)

Policy CodePolicy CS166NM.C

Change TypeCriteria revisedadded retreatment and documentation requirements

Effective DateFebruary 1, 2026

Next Review DateN/A

Key ActionObtain and include imaging demonstrating anatomic location and ≥50% stenosis (use CTA, MRA, DSA if duplex is insufficient) and ensure medical record documents symptoms and functional impact for prior authorization.

SourceLink

POLICY UPDATE CHANGES

Revised medically necessary coverage criteria to require imaging results of the target vessel show anatomic location and a moderate-severe stenosis (50% or greater) using examples including digital subtraction angiography.

Retreatment of a previously treated vessel due to in‑stent restenosis is proven and medically necessary when recurrent symptoms, impaired ADLs/work, and imaging showing ≥50% stenosis (or alternate imaging if duplex is insufficient) are present.

Added requirement that patient medical records must fully support medical necessity (history, physical exam, diagnostic test results) and may be requested during review.

Archived previous policy version CS166NM.B.

≥12 weeksSupervised exercise requirement

≤0.90

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

≥50%Imaging stenosis threshold

New MexicoApplies to

CS166NM.BArchived prior version

Coverage Criteria for Lower Extremity Endovascular Procedures

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

ALL of the following

Impaired ability to work and/or perform activities of daily living (ADL).
ALL of the following
- At least twelve (12) weeks of Supervised Exercise Therapy or a Structured Community‑Based Exercise Program.
- Pharmacologic therapy as appropriate (e.g., lipid‑lowering therapy, antihypertensive therapy, antiplatelet therapy, and/or anticoagulants).
- Smoking cessation counseling, if applicable.
Ischemic peripheral artery disease with Ankle‑Brachial Index (ABI) ≤ 0.90.
Imaging results of the target vessel (e.g., duplex ultrasound, computed tomography angiography [CTA], magnetic resonance angiography [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%, another imaging modality is required to demonstrate the extent of stenosis.
Imaging should define lesion location and degree of stenosis to support intervention.

ALL of the following

Recurrent symptoms attributable to the previously treated segment.
Impaired ability to work and/or perform activities of daily living (ADL).
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 ≥ 50%, another imaging modality is required to demonstrate the extent of stenosis.

ALL of the following

Endovascular revascularization procedures (e.g., stents, angioplasty, and/or atherectomy) are proven and medically necessary for treating CLTI when clinical diagnosis and applicable coding indicate limb threat (see Applicable Codes).
Patients with CLTI should receive guideline‑directed medical therapy (antithrombotic agents, lipid‑lowering, antihypertensive and glycemic control as indicated), preventive foot care, and smoking cessation counseling in conjunction with revascularization when appropriate.

Applicable Procedure and Diagnosis Codes

Applicable CPT CodesCPT

0238T	Transluminal peripheral atherectomy; iliac artery, each vessel.
0505T	Endovenous femoral-popliteal arterial revascularization with intravascular stent graft(s).
37220	Revascularization, endovascular, iliac artery, unilateral; with transluminal angioplasty.
37221	Revascularization, endovascular, iliac artery, unilateral; with transluminal stent placement(s).
37222	Revascularization, endovascular, additional ipsilateral iliac vessel; with transluminal angioplasty.
37223	Revascularization, endovascular, 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

Sample Applicable ICD-10 Codes (partial list in document)ICD-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 15

1/2

Atherosclerosis of bypass grafts (selected)ICD-10

I70.432	Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of calf
I70.433	Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of ankle
I70.434	Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of heel and midfoot
I70.435	Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot
I70.438	Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of lower leg
I70.439	Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site
I70.441	Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh
I70.442	Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of calf

Aneurysms and peripheral vascular disorders (selected)ICD-10

I72.3	Aneurysm of iliac artery
I72.4	Aneurysm of artery of lower extremity
I72.8	Aneurysm of other specified arteries
I72.9	Aneurysm of unspecified site
I73.00	Raynaud's syndrome without gangrene
I73.01	Raynaud's syndrome with gangrene

Infectious, congenital, injury, and prosthetic complication codes (selected)ICD-10

M86.*	Osteomyelitis codes (multiple specific codes listed)
L03.116	Cellulitis of left lower limb
Q27.32	Arteriovenous malformation of vessel of lower limb
S35.511A	Injury of right iliac artery, initial encounter
T82.312A	Breakdown (mechanical) of femoral arterial graft (bypass), initial encounter
T82.868A	Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter

Informational device identifiersmixed

P220021

FDA PMA identifier for DETOUR System

Ankle-Brachial Index (ABI) — threshold used in criteria

ABI thresholdAnkle-Brachial Index (ABI) ≤ 0.90

Clinical interpretationABI < 0.90 indicates peripheral artery disease (PAD)

Use in criteriaRequired objective ischemia threshold for claudication eligibility

Imaging stenosis threshold — general

General imaging stenosis thresholdImaging must demonstrate a moderate-severe stenosis (≥ 50%) of the target vessel

Applicable modalities (examples)

Provider Actions, Prior Authorization, and Documentation Requirements

Prior Authorization

Imaging requirement for prior authorization

Prior authorization reviews may require imaging that documents the anatomic location and demonstrates a moderate-to-severe stenosis (≥50%) of the target vessel. Acceptable imaging includes duplex ultrasound, CTA, MRA, or invasive angiography. If duplex ultrasound does not demonstrate ≥50% stenosis, an alternative imaging modality (CTA, MRA, or digital subtraction/invasive angiography) must be provided to demonstrate the extent of stenosis.

Acceptable imaging: duplex ultrasound, CTA, MRA, digital subtraction/invasive angiography
Stenosis threshold for PA: ≥50%
If duplex ultrasound <50% → provide alternative imaging modality

Prior Authorization

Retreatment for in‑stent restenosis requires documentation

Retreatment for in‑stent restenosis will require documentation that the member has recurrent, clinically significant symptoms (for example, lifestyle‑limiting claudication) and impaired ability to work or perform activities of daily living (ADLs). In addition, imaging of the previously treated vessel must demonstrate the anatomic location and a moderate‑severe stenosis (≥50%). If duplex ultrasound does not meet the stenosis threshold, provide CTA, MRA, or digital subtraction/invasive angiography.

Background and Evidence

Background: Peripheral artery disease (PAD) is atherosclerotic narrowing of limb arteries that reduces blood flow to the legs. PAD ranges from asymptomatic disease to exertional leg pain (claudication) and may progress to Chronic Limb‑Threatening Ischemia (CLTI), which risks tissue loss and amputation.

Claudication is exertional leg pain, numbness, or cramping that is relieved by rest; management emphasizes guideline‑directed medical therapy and structured exercise, with revascularization considered for lifestyle‑limiting symptoms that persist despite conservative measures.

inv-04 (evidence overlap): General evidence references included in coverage considerations

General evidence references included in coverage considerations

Evidence sources: Key evidence cited includes systematic reviews and meta-analyses (Pegler et al., Fakhry et al., Vemulapalli et al.), randomized trials (BEST-CLI), and guideline statements from ACC/AHA and SVS that inform comparative effectiveness and appropriateness of interventions

Referenced throughout Clinical Evidence and Clinical Practice Guidelines sections

Definitions and Key Terms

Ankle-Brachial Index (ABI) definition

DefinitionAnkle-Brachial Index (ABI) compares systolic blood pressure in the ankle to the arm; ABI < 0.90 indicates peripheral artery disease (PAD)

Clinical useUsed as objective ischemia measure in coverage criteria for claudication and CLTI

ReferenceGornik et al., 2024 cited in policy definitions

Chronic Limb-Threatening Ischemia (CLTI) definition

DefinitionChronic Limb-Threatening Ischemia (CLTI): chronic (≥ 2 weeks) ischemic rest pain, nonhealing wound/ulcers or gangrene in one or both legs attributable to objectively proven arterial occlusive disease

Nomenclature noteCurrent term evolved from 'critical limb ischemia' to reflect chronic, limb‑threatening nature

Policy Revision History

2026-02-01Revised coverage criteriaLatest

Revised medically necessary coverage criteria to require imaging of the target vessel showing anatomic location and a moderate–severe stenosis (50% or greater), adding digital subtraction angiography as an example modality.

2026-02-01Added retreatment criteria

Added language that retreatment for in-stent restenosis is proven and medically necessary when recurrent symptoms, impaired ADLs/work, and imaging demonstrate ≥50% stenosis (with alternate imaging required if duplex ultrasound is insufficient).

Policy Summary

PayerUnitedHealthcare

PolicyLower Extremity Endovascular Procedures (for New Mexico Only)

Policy CodePolicy CS166NM.C

Change TypeCriteria revisedadded retreatment and documentation requirements

Effective DateFebruary 1, 2026

Next Review DateN/A

SourceLink

On This Page

Duplex ultrasound, CTA, MRA, invasive angiography (digital subtraction angiography added as example)

When duplex insufficientIf duplex ultrasound does not demonstrate ≥50% stenosis, another imaging modality is necessary

Imaging stenosis threshold (alternate index)

Stenosis threshold50% or greater

Policy revision noteReplaced prior wording to require imaging of the target vessel and included digital subtraction angiography as example

Retreatment applicationApplies to both new interventions and retreatment for in‑stent restenosis

Stenosis threshold — >= 50% on imaging

Stenosis threshold>= 50% stenosis on imaging

Imaging modalitiesDuplex ultrasound, CTA, MRA, or digital subtraction angiography; alternative imaging required if duplex does not show ≥50%

Context of useRequired for retreatment of previously treated vessel for in‑stent restenosis and for initial revascularization criteria

Clinical requirements: recurrent symptoms AND impaired ability to work/perform ADLs
Imaging requirement: anatomic location and ≥50% stenosis on duplex, CTA, MRA, or invasive angiography
If duplex ultrasound does not show ≥50% stenosis → submit alternative imaging

Denial Risk

Documentation sufficiency risk

The patient's medical record must contain documentation that fully supports medical necessity for the requested service. Lack of adequate, legible documentation maintained in the medical record — including history, exam, and diagnostic test results — may result in denial of authorization or retroactive reimbursement actions.

Medical record must be legible and available on request
Insufficient documentation may lead to denial or retroactive recoupment

Denial Risk

Coding‑related denial risks

Claims that report certain graft complication and arterial injury diagnosis codes (for example, T82.x series for graft mechanical complications, leakage, thrombosis, and embolism; S35.x or S81.x series for arterial injury or open wounds) may be subject to additional review or denial if documentation does not clearly support the medical necessity of endovascular intervention.

Be aware of coding-related denial risk for graft complication codes (T82.3xx, T82.8xx, T82.9xx) and arterial injury/open wound codes (S35.x, S81.x)
Provide clear clinical rationale and supporting imaging when these codes are present

Documentation Required

Medical records supporting necessity

Medical records used for review should include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures that support the PAD diagnosis and the need for the requested intervention. Documentation should be legible, maintained in the patient's chart, and made available upon request.

Required elements: history, physical exam, diagnostic test results (ABI, imaging)
Records must be legible and retrievable on request

Documentation Required

Clinical documentation expectations

Documentation should explicitly support the diagnosis of peripheral artery disease, describe symptom severity (e.g., lifestyle‑limiting claudication or rest pain), detail prior conservative therapies and response, and characterize lesion features (anatomic location, degree of stenosis, lesion length, prior stent/graft history). For retreatment, document prior procedure details and interval symptom progression.

Support PAD diagnosis and symptom severity
Describe prior conservative therapy and clinical response
Describe lesion characteristics: location, stenosis %, length, calcification, prior stent/graft details

Documentation Required

Required medical record documentation

The patient's medical record must contain, at a minimum, the following items to support medical necessity during reviews: history and symptom description, physical examination findings, ankle‑brachial index (ABI) when available, imaging reports that demonstrate anatomic location and ≥50% stenosis (or alternative imaging if duplex is inconclusive), documentation of supervised exercise and other conservative therapies tried and failed, indication of impaired ADLs or work limitations when applicable, and procedural history including dates and devices for prior interventions.

Minimum required records: history, physical exam, ABI (if available)
Imaging reports showing anatomic location and ≥50% stenosis (if duplex inconclusive → CTA/MRA/angiography)
Documentation of ≥12 weeks supervised exercise or structured program and pharmacologic therapy trial
For retreatment: prior procedure dates, stent/graft details, and interval symptoms

Documentation Required

Conservative therapy considerations

Conservative therapies should be documented in detail when used as alternatives to revascularization. This includes the type of therapy (e.g., supervised exercise therapy, structured community program), program duration and frequency, participant adherence, individualized counseling or coaching provided, pharmacologic therapies attempted (including agents and duration), and smoking cessation interventions when applicable. If supervised exercise was not completed, document reasons why it was not feasible or effective.

Document type, duration, frequency, and adherence for supervised exercise therapy (minimum 12 weeks recommended)
Document pharmacologic therapy trials and smoking cessation efforts
If exercise therapy not feasible or attempted, provide rationale

Prior Authorization

Conservative therapy first

Guideline‑directed care recommends that patients with intermittent claudication first receive medical therapy and structured supervised exercise. Endovascular revascularization should be considered only for patients with lifestyle‑limiting symptoms despite adequate medical therapy and a completed trial of supervised exercise (typically a minimum of 12 weeks). Ensure records document guideline‑directed medical therapy and the supervised exercise trial before requesting authorization for intervention for claudication.

First‑line: guideline‑directed medical therapy + supervised exercise (minimum 12 weeks)
Revascularization considered for persistent lifestyle‑limiting claudication despite these measures

Treatment implicationEndovascular revascularization is proven and medically necessary for treating CLTI when diagnoses align with applicable codes

Supervised Exercise Therapy definition

DefinitionSupervised Exercise Therapy: facility-based program supervised by qualified clinicians focusing on intermittent walking; sessions of 30–45 minutes active walking within a 60-minute session, at least 3 times/week for a minimum of 12 weeks

Training detailsIntermittent walking to moderate-to-maximum claudication pain with rest periods and progressive increases as tolerated

Setting and personnelUsually in hospital or outpatient facility; supervised by clinical exercise physiologists or nurses with exercise training experience

Structured Community-Based Exercise Program definition

DefinitionStructured Community-Based Exercise Program: home or community-based, self-directed walking program prescribed by qualified health care professionals with guidance, possible behavioral support, and may include periodic supervised sessions

Program componentsIncludes individual counseling, activity monitoring, and behavioral change techniques as appropriate

Relation to supervised therapyAlternative to facility-based supervised therapy when supervised program is not feasible; considered in conservative therapy requirements

Claudication — definition

DefinitionClaudication: fatigue, cramping, aching, pain, or other discomfort in lower extremity muscles consistently induced by walking and relieved by rest (usually within ~10 minutes)

Functional descriptorWhen it limits functional status it is termed functionally limiting Claudication

Clinical contextManifestation of chronic symptomatic peripheral artery disease (PAD)

Chronic limb-threatening ischemia (CLTI) — definition (duplicate)

DefinitionChronic limb-threatening ischemia (CLTI): advanced PAD with rest pain, tissue loss, or gangrene that threatens limb viability

Clinical significanceAssociated with high risk for amputation and requires evaluation for revascularization; best medical therapy recommended

DistinctionReflects chronic and limb‑threatening nature distinct from acute limb ischemia

Claudication — lifestyle-limiting exertional leg pain definition

DefinitionClaudication: lifestyle-limiting exertional leg pain due to peripheral artery disease for which revascularization may be considered after failure of guideline‑directed medical therapy and structured/supervised exercise

Treatment pathwayGuidelines recommend medical therapy and structured exercise first; revascularization considered for persistent lifestyle‑limiting symptoms

Risk factors/contextPAD commonly affects leg arteries and may be asymptomatic in many individuals

In‑stent restenosis retreatment — definition

DefinitionIn‑stent restenosis retreatment: retreatment of a previously treated vessel due to recurrent symptoms and imaging‑demonstrated moderate‑severe stenosis (≥50%) with associated impaired ADLs/work considered in eligibility

Documentation requiredPrior authorization reviewers will require documentation of recurrent symptoms, impaired ability to work/perform ADLs, and imaging showing anatomic location and ≥50% stenosis; alternative imaging if duplex inadequate

Applies toRetreatment for non‑limb‑threatening lower extremity ischemia of aortoiliac and/or femoropopliteal arteries

In-stent restenosis — short definition

DefinitionIn-stent restenosis: recurrent stenosis within a previously treated stented arterial segment that may cause recurrent claudication symptoms

Imaging criterionModerate-severe stenosis defined as ≥50% on imaging

Clinical consequenceMay prompt retreatment when associated with recurrent symptoms and functional impairment

Clarified documentation requirements

Added explicit medical record documentation requirements stating records must fully support medical necessity (history, exam, diagnostic tests) and be made available on request.

2026-02-01Administrative update

Updated Clinical Evidence and References sections and archived previous policy version CS166NM.B.