Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
Therapeutic options for atherosclerotic carotid stenosis include medical therapy alone, carotid endarterectomy (CEA) and medical therapy, or carotid artery stenting (CAS) and medical therapy. CEA has been considered the gold-standard to restore vascular patency in the surgical management of carotid artery stenosis. CAS is a less invasive surgical procedure, and has become an alternative to CEA particularly in symptomatic patients who are at high risk for surgically-related morbidity and mortality.
Coverage decision: Covered with conditions
Coverage for the procedure is limited to the placement of a carotid stent concurrently with the placement of an embolic protection device that both have to be FDA-approved. Conditions that must be met for their insertion to be payable include:
- The procedure must be done in a CMS accredited facility AND
- The patient must meet the definition of high risk for complications during a carotid endarterectomy (CEA) AND
- The patient has carotid artery stenosis > 50% and is symptomatic OR
- The patient has carotid artery stenosis ≥80% and is asymptomatic.
Carotid Artery Stenting of intracranial arteries, vertebral arteries or the basilar artery is not covered.
Definition of high risk:
Patients at high risk for complications during CEA are defined as having significant comorbidities and/or anatomic risk factors (e.g. recurrent stenosis and/or previous radical neck dissection). Significant comorbid conditions include but are not limited to:
- Congestive heart failure (CHF) class III/IV;
- Left ventricular ejection fraction (LVEF) < 30 %;
- Unstable angina;
- Contralateral carotid occlusion;
- Recent myocardial infarction (MI);
- Previous CEA with recurrent stenosis;
- Prior radiation treatment to the neck; and
- Other conditions that were used to determine patients at high risk for CEA in the prior carotid artery stenting trials and studies, such as ARCHER, CABERNET, SAPPHIRE, BEACH, and MAVERIC II.
Definition of symptomatic for carotid artery stenosis includes one or more of the following:
- The patient has a history of carotid transient ischemic attack (distinct focal neurological dysfunction persisting less than 24 hours) or
- The patient has transient monocular blindness (amaurosis fugax) or
- The patient has focal cerebral ischemia producing a non-disabling stroke (modified Rankin scale < 3 with symptoms for 24 hours or more). Patients who have had a disabling stroke with a modified Rankin scale ≥ 3 shall be excluded from coverage.
The State Health Technology Clinical Committee (HTCC) reviewed CAS on September 20, 2013. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that CAS is a covered benefit with conditions. Complete information on this HTCC determination is available here: What we're working on | Washington State Health Care Authority. L&I has adopted the above coverage decision effective October 1, 2014.
Implementation of the Determination
CAS may be used only for care of a condition accepted on the claim. All requests require prior authorization.
CPT Codes covered: 37215, 37217, 0075T and 0076T
CPT Codes not covered: 37216 and 61635