Lower Extremity Invasive Diagnostic and …
UnitedHealthcare? Commercial Medical Policy
Lower Extremity Invasive Diagnostic and Endovascular Procedures
Policy Number: 2021T0602F Effective Date: July 1, 2021
Instructions for Use
Table of Contents
Page
Coverage Rationale ....................................................................... 1
Documentation Requirements......................................................2
Definitions ...................................................................................... 3
Applicable Codes .......................................................................... 4
Description of Services ................................................................. 5
Clinical Evidence ........................................................................... 5
U.S. Food and Drug Administration ............................................. 7
References ..................................................................................... 8
Policy History/Revision Information ............................................. 9
Instructions for Use ....................................................................... 9
Related Commercial Policies ? Pneumatic Compression Devices ? Surgical and Ablative Procedures for Venous
Insufficiency and Varicose Veins
Community Plan Policy ? Lower Extremity Invasive Diagnostic and
Endovascular Procedures
Medicare Advantage Coverage Summary ? Cardiovascular Diagnostic Procedures
Coverage Rationale
Note: This policy does not apply to upper extremities.
Diagnosis
Lower extremity vascular angiography is proven and medically necessary for evaluating arterial disease, aneurysms, perivascular masses and trauma related injuries of the lower extremity under certain circumstances.
Angiography for known chronic lower extremity arterial disease (peripheral vascular disease, occlusion or stenosis of arteries of the leg, claudication and limb ischemia) requires all the following:
Abnormal ankle-brachial index (ABI) or an abnormal computed tomography angiography (CTA), magnetic resonance angiography (MRA) or duplex ultrasound; and One of the following: o Claudication ? as evidenced with an ABI 0.90; or o Limb Ischemia ? as evidenced with an ABI ................
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